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What was the dosage of drug 'INFLIXIMAB'? | Timely Monitoring of Inflammation by Fecal Lactoferrin Rapidly Predicts Therapeutic Response in Inflammatory Bowel Disease.
Fecal lactoferrin (FL) levels may mirror drug-induced changes in inflammation in ulcerative colitis and Crohn disease in a timely way and could be used to assess loss of response (LOR) to biologics.
This study is a retrospective outcome review in 61 patients on adalimumab, infliximab, or vedolizumab managed in our center and followed for 6 to 24 months. Patients were 1) in clinical remission or 2) were experiencing possible LOR.
For group 1, in 71% of 31 patients, FL slowly increased during the therapeutic interval (R2 = 0.769; P < 0.001), thus reflecting increasing inflammation as drug concentrations decreased. In the remaining patients, FL was undetectable throughout the therapeutic interval because of a stronger suppression of inflammation. For group 2, in 30 patients negative for infections, FL levels measured 1 to 3 days after infusion/injection compared to preadministration values either increased (nonresponders)-in these patients the medication was switched to another class; partially decreased (partial responders)-the therapeutic interval was shortened; or were normal throughout (responders)-causes for symptoms unrelated to disease activity were found for all. After FL-based management, 3-month standardized clinical scores were normalized in both partial responders (0.58 ± 0.21 vs 0.13 ± 0.09; P < 0.001) and nonresponders (0.81 ± 0.17 vs 0.12 ± 0.08; P < 0.001), and FL levels dropped by up to 99%.
Levels of FL reflect drug-induced changes in mucosal inflammation in a timely way, thus enabling rapid assessment of therapeutic response in patients with ulcerative colitis and with Crohn disease. In patients with suspected LOR, FL levels before and after infusion/injection accurately separated responders, partial responders, and nonresponders. The strategy proposed here is simple, accurate, and easily applicable to clinical practice.
INTRODUCTION
Response to therapy in inflammatory bowel disease (IBD)—both ulcerative colitis (UC) and Crohn’s disease (CD)—has classically been monitored by the severity of clinical symptoms1 and by endoscopy, a more objective but also more expensive and invasive tool. More recently, in patients on biologics, the measurement of drug trough levels (TL) and of antidrug antibodies—a strategy known as therapeutic drug monitoring (TDM)—has been widely used to assess/manage loss of response (LOR) and primary nonresponse (PNR).2 Although TDM-based management may improve outcomes in IBD,2,3 this strategy is expensive and has practical shortcomings.4-9 Ideally, it is the individual patient disease burden that therapy should target.4, 10, 11
Fecal markers of inflammation, specifically fecal lactoferrin (FL) and fecal calprotectin (FC), seem to be accurate indicators of intestinal mucosa inflammation,1 but their definitive role in IBD management still needs to be elucidated.12 In particular, it is unclear whether stool markers can accurately indicate immediate therapy-induced changes in IBD activity, a necessary feature for the management of LOR. Previous studies have shown that FC levels in patients with IBD on biologics increase during the therapeutic interval—thus reflecting in a timely way the increasing inflammatory activity resulting from the progressive neutralization of the medication.13 We have since confirmed such findings with FL and leveraged them to routinely evaluate patients’ immediate response to treatment when experiencing an apparent clinical flare. In this retrospective study we report the relevant data.
METHODS
Study Design and Study Population
This retrospective study enrolled 61 patients with UC or CD diagnosed and staged according to established criteria,14 treated with biologics (infliximab, adalimumab, and vedolizumab), and monitored as standard of care in our IBD center through the measurement of FL levels. Five of these patients were treated with infliximab-dyyb (Inflectra), but no distinction was made between Inflectra and infliximab-Remicade. The FL levels and clinical/laboratory data were collected from the patients’ electronic medical records. Data collected involved 2 different groups of patients.
The first group (therapeutic interval group) consisted of patients on maintenance monotherapy in clinical remission; data included FL at baseline (measured within 1 month of initiating therapy) and FL measured at different times during the biologic therapeutic interval (8 weeks for vedolizumab/infliximab, 2 weeks for adalimumab). The objective of this study was to confirm our original observation (obtained with FC) showing that in patients responding to biologics, fecal inflammatory markers mirror mucosal inflammation, which is inversely correlated to serum drug concentrations, in a timely way.13 It was anticipated that FL fluctuation during the therapeutic interval would not be detected in patients in profound/biologic remission.
The second group (patients with suspected LOR) included 30 patients on maintenance monotherapy with biologics apparently experiencing a disease flare as judged by pain and/or diarrhea and/or bleeding in whom stool studies (Clostridioides difficile, stool culture, ova and parasites) had excluded infection. No steroids or other medications were prescribed before the index FL tests. The FL levels were measured 1 to 3 days before and 2 to 3 days after infusion/injection (Fig. 1). Patients with elevated FL levels before infusion/injection were managed according to changes observed afterward. When FL returned to normal levels, patients were considered full responders and non-IBD causes of symptoms were sought. When FL decreased but did not return to normal, patients were considered partial responders and the therapeutic interval was decreased (by 2-4 weeks for infliximab/vedolizumab and by 7 days for adalimumab). If patients were already on the shortest interval, then an immunomodulator was added. When FL levels increased after infusion/injection, patients were considered nonresponders and the medication was switched to a new one. We anticipated such increases in inflammation and FL levels in nonresponders because of the progressive, time-dependent nature of uncontrolled disease activity. If patients failed or had already failed the available biologic agents, then they underwent surgery. Patients in whom the FL levels were normal before infusion/injection (in all of them levels remained normal afterward) were also considered full responders and no therapeutic changes were made. However, non-IBD causes for the symptoms were sought.
FIGURE 1. Stool marker-based strategy for the evaluation of patients with IBD with suspected LOR to biologics.
Outcome data in this group included clinical assessment (see “Assessment of Clinical Disease Activity” below) and additional predrug infusion/injection FL measurements and/or imaging/colonoscopy performed at 3 months after the index FL determination. Patients were also followed in the long term. The goal of this study was to show that a stool marker–based approach can separate responders from partial responders and nonresponders based on symptom resolution and improvement of objective parameters of disease activity.
There was no direct patient involvement. The study conformed to the guidelines of the 1975 Declaration of Helsinki as reflected by Carilion Clinic Ethical Committee approval. No patient consent was deemed necessary.
Biomarker Testing
The FL was measured in samples collected during the first bowel movement of the day by the LACTOFERRIN SCAN (TECHLAB, Blacksburg, VA), an enzyme-linked immunosorbent assay. Values ≤7.24 μg/mL are considered normal15. At the Carilion Clinic Laboratory, the lower limit to which the linearity of results has been validated is 6.25 μg/mL—which was the absolute value reported and analyzed for all results ≤6.25 μg/mL. The FL values are presented by standard decimal approximations of the real number by excess or defect. Routine blood and stool studies were performed using established methods.
Assessment of Clinical Disease Activity
Clinical assessment was based on the Harvey-Bradshaw Index (HBI) for CD and the Partial Mayo Scoring Index (PMSI) for UC.16 For HBI, scores of <5, 5 to 7, 8 to 16, and >16 define remission, mild, moderate, and severe disease activity. The same activities are defined by the scores of 0 to 1, 2 to 4, 4 to 6, and 7 to 9 for PMSI.
Statistical Analysis
Therapeutic interval group
This analysis focused on the relationship between FL values and the timing of test determination during the therapeutic interval for the 3 medications. Because the therapeutic intervals differed for the 3 medications (2 weeks for adalimumab and 8 weeks for infiximab/vedolizumab) and because the individual absolute FL values also differed among patients, the data were normalized to percentage of baseline FL values (values before starting any therapy) and percentage of therapeutic interval. All treatments were considered together because when treatment was considered as a second variable in the model and when interaction of treatment and timing was considered, neither one was found to be statistically significant. A repeated-measures model using the percentage of FL as the outcome of the model was run initially, which showed the residuals to be right-skewed. Hence, FL values were log-transformed and percentages of baseline ln (FL) were calculated, with the resulting model residuals appearing much closer to being normally distributed. Data were then analyzed again with a repeated-measures model using R version 3.6.1 and specific packages.17, 18 The results of the analysis of variance F test for the effect of therapeutic interval were calculated as “conditional” R2, a parameter that includes random subject variability.19
Patients with suspected LOR
These patients were divided into 2 subgroups: those who experienced a decrease in FL after treatment and those who experienced an increase in FL after treatment (see Fig. 1). These 2 subgroups were modeled separately. Patients with FL levels within normal limits before and after drug infusion/injection were not included in the analysis—because by definition they were not experiencing a true disease flare. This analysis was a descriptive analysis to summarize the changes in FL after drug administration relative to baseline. As in the first (therapeutic interval) group, FL values were log-transformed before analysis. Analysis of HBI and PMSI before and after treatment (at 3-month follow-up) was performed by independent (2-sample) t tests. To uniformly analyze the data, these clinical indices were rescaled to be between 0 and 1 by dividing each score by the maximum value for each scale; for HBI, the value 16 was used as the maximum value because all the scores >16 are considered severe (and 16 was also the highest value of the HBI in the dataset).
RESULTS
Therapeutic Interval Group
Table 1 shows the clinical features of the 31 patients in clinical remission tested for FL at various timepoints during the therapeutic interval. Of these, 68% had CD and 32% had UC, 58% were on infliximab, and 19% and 23% were on vedolizumab and adalimumab, respectively. Most patients with CD had nonstricturing/nonpenetrating colonic or ileocolonic disease, and most patients with UC had pancolitis.
TABLE 1. Therapeutic Interval Group Characteristics
Demographics n = 31
Age, y, median (IQR) 46 (24)
Sex (men/women) 14/17
Smoker (% current, former, never) 16, 45, 39
Disease characteristics
Disease type
CD, n (%) 21 (68)
UC, n (%) 10 (32)
Disease duration, y, median (IQR) 6 (9)
Biologic, n (%)
Infliximab 18 (58)
Vedolizumab 6 (19)
Adalimumab 7 (23)
CD location, n (%)
L1: ileal 4 (20)
L2: colonic 6 (26)
L3: ileocolonic 11 (54)
CD behavior, n (%)
B1: nonstricturing, nonpenetrating 16 (74)
B2: stricturing 3 (16)
B3: penetrating 2 (10)
UC location (%)
E1: Ulcerative proctitis 1 (10)
E2: Left-sided (distal) 2 (20)
E3: Extensive (pancolitis) 7 (70)
Table 2 shows the FL values at baseline (before starting therapy) and at an early and a late timepoint during the 8-week (infliximab/vedolizumab) or 14-day (adalimumab) therapeutic interval. Baseline FL values varied among patients. However, in all patients FL values dropped significantly (up to 99.9%) after the start of therapy, consistently with observed clinical response. In 22/31 patients (71%), FL levels increased moving toward the infusion/injection day, with the highest values recorded immediately before drug administration and the lowest values immediately afterward. The results of the analysis of variance F test for the effect of therapeutic interval showed a significant (P < 0.001; conditional R2 = 0.769) progressive increase of FL over time. In 9/31 (29%) of patients, FL levels were below detectability throughout the interval and were excluded from the analysis. On average, patients with undetectable FL values during the therapeutic interval had baseline FL levels 9 times lower than patients with detectable levels. This finding suggests that standard medication dosage/interval induced a deeper remission (with persistently undetectable FL) in patients with a lower disease burden.
TABLE 2. FL During Therapeutic Interval
Patients Treated With Infliximab—FL Values (μg/mL)
Patient number, disease type, location-extent Baseline Interval First Value (week number) Interval Last Value (week number)
1 UC—E3 9888 6.25 (3) 622 (5)
2 UC—E3 1653 6.25 (5) 19 (6)
3 UC—E2 362 6.25 (4) 142 (6)
4 UC—E2 541 6.25 (1) 43 (6)
5 CD—L3 400 6.25 (5) 9 (6)
6 CD—L3 407 6.25 (1) 6.25 (8)
7 CD—L3 330 72 (3) 194 (8)
8 CD—L2 437 47 (1) 238 (8)
9 UC—E3 444 19 (3) 85 (4)
10 CD—L1 9 6.25 (1) 6.25 (6)
11 CD—L3 362 6.25 (2) 241 (8)
12 CD—L1 67 6.25 (1) 6.25 (7)
13 CD—L2 448 6.25 (3) 6.25 (8)
14 CD—L2 7285 683 (1) 1007 (5)
15 CD—L3 5923 6.25 (1) 18 (8)
16 CD—L2 583 61 (3) 65 (7)
17 CD—L3 218 36 (1) 152 (8)
18 UC—E3 4262 6.25 (1) 10 (8)
Patients Treated With Vedolizumab— FL Values (μg/mL)
Patient number, disease type, location-extent Baseline Interval First Value (week number) Interval Last Value (week number)
19 UC—E3 4097 10 (1) 40 (7)
20 UC—E3 4019 73 (1) 380 (6)
21 UC—E1 46 6.25 (3) 6.25 (5)
22 UC—E3 3978 66 (1) 420 (6)
23 CD—L2 1464 66 (4) 172 (8)
24 CD—L3 337 6.25 (3) 6.25 (6)
Patients Treated With Adalimumab— FL Values (μg/mL)
Patient number, disease type, location-extent Baseline Interval First Value (day number) Interval Last Value (day number)
25 CD—L2 654 6.25 (3) 6.25 (12)
26 CD—L3 297 6.25 (5) 6.25 (10)
27 CD—L3 166 29 (2) 98 (13)
28 CD—L3 97 6.25 (7) 6.25 (10)
29 CD—L3 434 43 (4) 68 (13)
30 CD—L1 57 20 (3) 30 (12)
31 CD—L1 93 10 (4) 63 (13)
E1 indicates proctitis; E2, left sided colitis; E3, pancolitis; L1, ileal; L2, colonic; L3, ileocolonic.
Fig. 2 is a scatterplot with a Loess smoother that shows the pattern of percentage of baseline FL levels as a percentage of therapeutic interval. Supplementary Fig. 1 is a line graph that connects the individual patient values and shows the upward trend for all patients. Hence, as the therapeutic interval progresses, FL levels increase—more so toward the end of the interval—thus reflecting the surge in inflammation as the drug concentration decreases over time.13
FIGURE 2. Loess smoother of FL changes during the therapeutic interval in patients with IBD treated with biologics. Colored points denote patients’ first (yellow) and subsequent (purple) measurements.
Patients With Suspected LOR
There were 30 consecutive patients on maintenance therapy experiencing a possible disease flare (newly reported pain and/or diarrhea and/or bleeding). Their features are shown in Table 3. Their mean age was 44 years, 57% were men, 63% had CD, 67% were on infliximab, 30% were on adalimumab, and 3% were on vedolizumab. The majority of patients with CD had colonic or ilecolonic nonstricturing/nonpenetrating disease. The majority of patients with UC had pancolitis.
TABLE 3. Characteristics of Patients With Suspected LOR
Demographics n = 30
Age, y, median (IQR) 44 (29)
Sex (men/women) 17/13
Smoker (% current, former, never) 14, 41, 45
Disease characteristics
Disease type
CD, n (%) 19 (63)
UC, n (%) 11 (37)
Disease duration, y, median (IQR) 9 (11)
Biologic, n (%)
Infliximab 20 (67)
Vedolizumab 1 (3)
Adalimumab 9 (30)
CD location, n (%)
L1: ileal 3 (16)
L2: colonic 7 (37)
L3: ileocolonic 9 (47)
CD behavior, n (%)
B1: nonstricturing, nonpenetrating 16 (84)
B2: stricturing 2 (11)
B3: penetrating 1 (5)
UC location (%)
E1: Ulcerative proctitis 2 (18)
E2: Left-sided (distal) 3 (27)
E3: Extensive (pancolitis) 6 (55)
The FL values before and after drug administration (see Fig. 1) separated 3 subgroups. In the first subgroup, FL was elevated before infusion/injection and continued to increase thereafter ("nonresponders"). In the second subgroup, FL was also elevated before infusion/injection but decreased significantly without returning to normal after infusion/injection ("partial responders"). A third subgroup displayed normal FL values after drug administration and in 9/10 patients even before drug administration ("responders").
Table 4 shows the clinical picture of these 3 subgroups of patients at the time of drug administration, the FL values before and after infusion/injection, the management strategy, and the 3-month outcomes—including the clinical indices before/after the management decision and the follow-up FL measured before infusion/injection (also expressed as a percentage of premanagement values). The total follow-up time and additional changes in disease management are also shown in Table 4. In the first subgroup, the biologic was switched (in most patients to a different class). Two of these patients failed the new medication and required surgery. One of these patients had already failed other biologics and directly opted for surgery. One patient underwent urgent surgery because of severe colitis and died of complications during surgery. Total follow-up time in this group averaged 18 months. In the second subgroup, FL decreased on average by approximately 70% after infusion/injection. In these patients, the therapeutic interval was decreased by 2 to 4 weeks (infliximab/vedolizumab) or 1 week (adalimumab). In 1 patient, another medication (azathioprine 3 mg/Kg) was added because the patient was already on the shortest biologic therapeutic interval. Total follow-up time in this group averaged 19 months. In the third subgroup of patients (responders), the therapy was left unchanged and other causes for the symptoms were sought and found for all.
TABLE 4. Patients With Suspected LOR: Clinical Picture, FL Levels, Management, and Follow-Up
Nonresponders
Patient Number Disease Type Clinical Picture at Infusion/Injection (medication type and frequency) FL (μg/mL) Pre-/ Postmedication (± % Δ) IBD Care Management FL (μg/mL) Response to Change in Care (± % Δ) HBI (before/after management becision) PMSI (before/after management decision) Total Follow-Up
1 UC Moderate diarrhea, abdominal pain (infliximab q8w) 80/94 (+15%) Medication change to vedolizumab 21 (–78%) N/A 4/0 6 months; no clinical changes
2 UC Moderate diarrhea, abdominal pain, rectal bleeding (infliximab q8w) 90/249 (+64%) Medication change to vedolizumab 46 (–81%) N/A 6/2 18 months; later failure of vedolizumab; now on tofacitinb
3 UC Moderate diarrhea, abdominal pain, rectal bleeding (adalimumab q2w) 146/216 (+32%) Medication change to vedolizumab 15 (–93%) N/A 7/1 12 months; no clinical changes
4 UC Severe diarrhea, abdominal pain, rectal bleeding (infliximab q4w—had failed adalimumab and vedolizumab) 983/3143 (+69%) Total abdominal colectomy with ileostomy N/A N/A 8/0 24 months; no clinical changes
5 CD Severe diarrhea, abdominal pain, rectal bleeding (adalimumab q2w) 243/381 (+36%) Medication change to infliximab 6.25 (–97%) 12/1 N/A 24 months; no clinical changes
6 CD Moderate diarrhea, abdominal pain (vedolizumab q8w) 313/450 (+30%) Medication change to adalimumab 62 (–86%) 12/4 N/A 14 months; no clinical changes
7 UC Severe diarrhea, abdominal pain (infliximab q8w) 878/928 (+5%) Medication change to vedolizumab 6.25 (–93%) N/A 8/2 12 months; no clinical changes
8 UC Severe diarrhea abdominal pain (infliximab q6w; steroid-resistant) 3442/3577 (+3%) Total abdominal proctocolectomy after failing vedolizumab 125 (–97%) N/A 9/1 24 months; developed pouchitis—controlled by antibiotics
9 UC Diarrhea, abdominal pain, rectal bleeding (infliximab q8w—had failed adalimumab) 313/330 (+5%) Total abdominal colectomy and ileostomy after failing vedolizumab N/A N/A 8/1 24 months; no clinical changes
10 UC Severe diarrhea, abdominal pain, rectal bleeding (infliximab q4w) 2081/3593 (+22%) Total abdominal colectomy N/A N/A 9/1 Died of complications at surgery
Partial responders
Patient Number Disease Type Clinical Picture at Infusion/Injection (medication type and frequency) FL (μg/mL) Pre-/Postmedication (± % Δ) IBD Care Management FL (μg/mL) Response to Change in Care (± % Δ) HBI (before/after management decision) PMSI (before/after management decision) Total Follow-Up
11 UC Severe diarrhea, abdominal pain (infliximab q8w) 744/573 (–23%) Shortened interval to 4 weeks 6.25 (–92%) N/A 5/0 48 months; normal colonoscopy at 24 months
12 CD Mild diarrhea, abdominal pain (infliximab q8w) 2059/519 (–75%) Shortened interval to 4 weeks 66 (–97%) 12/5 N/A 18 months; at 12 months normal colonoscopy and FL = 6.25 μg/mL
13 CD Diarrhea (infliximab q8w) 42/22 (–50%) Shortened interval to 5 weeks N/A 16/3 N/A 6 months; FL = 6.25 μg/mL
14 CD Moderate diarrhea, abdominal pain (infliximab q8w) 239/41 (–83%) Shortened interval to 6 weeks 7 (–97%) 8/2 N/A 6 months; no changes, then had to stop infliximab for prostate cancer
15 CD Moderate diarrhea, abdominal pain (infliximab q8w) 96/20 (–80%) Shortened interval to 6 weeks 26 (–73%) 13/4 N/A 24 months; no clinical changes
16 CD Moderate diarrhea, abdominal pain, rectal bleeding (adalimumab q2w) 108/38 (–65%) Shortened interval to 1 week 6.25 (–95%) 6/2 N/A 12 months; no clinical changes
17 CD Mild diarrhea (adalimumab q2w) 235/91 (–61%) Shortened interval to 1 week N/A 6/1 N/A 12 months; developed flare on adalimumab q1w with FL 341/181—switched to infliximab q8w; at 6 months FL = 16 μg/mL
18 CD Moderate diarrhea and abdominal pain (infliximab q8w) 477/62 (–87%) Shortened interval to 6 weeks 6.25 (–99%) 6/2 N/A 24 months; no clinical changes
19 UC Diarrhea, rectal bleeding (infliximab q8w) 6622/815 (–88%) Shortened interval to 4 weeks 6.25 (–99%) N/A 5/0 18 months; no clinical changes
20 CD Moderate diarrhea and abdominal pain (infliximab q4w) 3291/561 (–83%) Addition of azathioprine 6.25 (–99%) 7/2 N/A 24 months; no clinical changes
Responders
Patient Number Disease Type Clinical Picture at Infusion/Injection (medication type and frequency) FL (μg/mL) Pre/ Postmedication (± % Δ) IBD Care Management FL (μg/mL) Response to Change in Care (± % Δ) HBI (before/after management decision) PMSI (before/after management decision) Additional Notes and Total Follow-Up
21 CD Blood in stool (infliximab q8w) 18/6.25 (–65%) No action N/A 2/2 N/A Blood was urinary because of urinary stones; abatement of symptoms after stone surgery; 12 months
22 CD Rectal bleeding (infliximab q8w) 6.25/6.25 (0%) No action 6.25 (0%) 2/2 N/A Blood because of hemorrhoids; abatement of symptoms after hemorrhoidectomy; 48 months
23 UC Moderate diarrhea (adalimumab q2w) 6.25/6.25 (0%) No action 6.25 (0%) N/A 3/0 Symptoms suspected from food poisoning; symptoms improved within 1 week; 24 months
24 CD Moderate diarrhea (adalimumab q2w) 6.25/6.25 (0%) No action 6.25 (0%) 10/0 N/A Short gut syndrome; symptoms relieved after specific management; 18 months.
25 CD Moderate diarrhea and abdominal pain (infliximab q8w) 6.25/6.25 (0%) No action N/A 15/15 N/A No inflammation at upper and lower endoscopy, capsule endoscopy, imaging; likely nerve entrapment after previous abdominal surgery; managed symptomatically; 24 months
26 CD Abdominal pain (infliximab q8w) 6.25/6.25 (0%) No action 6.25 (0%) 2/0 N/A Umbilical hernia and gastroparesis; abatement of symptoms after surgery and treatment of gastroparesis; 12 months
27 CD Mild diarrhea (Adalimumab q2w) 6.25/6.25 (0%) No action N/A 3/0 N/A Symptoms abated after reduction in dietary fiber intake; 12 months
28 CD Rectal bleeding (adalimumab q2w) 6.25/6.25 (0%) No action 6.25 (0%) 2/2 N/A Blood because of hemorrhoids; no further action; 48 months
29 CD Diarrhea and bloating (infliximab q8w) 6.25/6.25 (0%) No action 6.25 (0%) 4/0 N/A Symptoms abated after reduction in dietary fiber intake; 24 months
30 CD Abdominal discomfort (adalimumab q2w) 6.25/6.25 (0%) No action 6.25 (0%) 1/1 N/A Symptoms spontaneously abated in 4 days, likely because of food poisoning; 12 months
In most patients, hemorrhoids were found to be responsible for rectal bleeding while pain and diarrhea were attributed to a number of causes including nerve entrapment, hernia, short gut syndrome, and food poisoning, which mostly resolved after adequate management. Total follow-up time in this group averaged 23 months. Fig. 3 graphically illustrates the results for 3 different patients representing nonresponders, partial responders, and responders.
FIGURE 3. FL levels in patients with IBD apparently losing response after a period of remission. A, Nonresponder (patient 3; see Table 4): FL levels before drug administration were elevated and increased further thereafter. The medication was switched and the patient regained response. B, Partial responder (patient 11; see Table 4): FL levels before drug administration were elevated and decreased afterward. The medication therapeutic interval was shortened and the patient regained response. C, Responder (patient 22; see Table 4): FL levels before drug administration were normal and did not change after drug administration. No changes were made in IBD medications and other causes of symptoms were sought (in this patient, bleeding resulted from hemorrhoids and ceased after surgery). Patient continued to respond to IBD medication. Day 0 arbitrarily indicates the time of the initial observation for each patient.
Disease severity was scored before and after (at 3 months) the management decision for all subgroups. Analysis of standardized clinical scores showed that in nonresponders the initial scores (at time of drug administration) were higher than in partial responders (P = 0.002). However, the subgroup-tailored management strategy led to a significant decrease in standardized clinical scores for both partial responders (0.58 ± 0.21 vs 0.13 ± 0.09; P < 0.001) and nonresponders (0.81 ± 0.17 vs 0.12 ± 0.08; P < 0.001). The FL level was measured (immediately before drug administration) at 3 months in all patients, except for those who had undergone surgery. It decreased on average by 88% and 97% compared to corresponding values at the time of index drug administration in nonresponders and partial responders, respectively.
DISCUSSION
LOR and PNR to biologic agents occur frequently in IBD.20, 21 Traditionally, management has involved empirical drug dose escalation with subsequent medication switch in the absence of symptomatic improvement.20, 21 More recently, TDM has gained popularity over this approach. A number of studies have indeed shown that TDM may impact the management of LOR and PNR and has also helped clarify some of their mechanistic aspects.2, 3 However, several clinical issues (most notably the absence of universally applicable TL) limit the routine use of TDM strategies in daily practice.4-9, 11, 13, 22 a more practical approach would be to directly evaluate medication impact on disease activity and inflammatory burden—of which FL/FC are excellent indicators.23-29 However, their precise role in IBD management is still partly undefined,12 and in particular it is unclear whether fecal markers may reflect immediate drug efficacy in a timely way—a feature needed to manage LOR.
In this retrospective study, we collected data generated in our clinical practice confirming initial FC data by our group13 and providing evidence that FL levels bear a fine time-sensitivity to drug-generated changes in inflammation. In 71% of patients in clinical remission, FL levels increased during the therapeutic interval with the highest values recorded immediately before infusion/injection—mirroring increasing inflammatory activity because of depletion of circulating drug levels in a timely way.13 Hence, the majority of patients with IBD successfully treated with biologics had FL levels above normal, especially approaching drug administration. This finding is significant because complete mucosal healing and normal fecal markers correlate with better outcomes in the long term.30, 31 However, dose escalation in all such patients would increase costs and potentially increase the risk of adverse effects.32 In patients with persistently normal FL levels during the entire therapeutic interval, baseline FL values were almost an order of magnitude lower than in the other patients, suggesting that the standard biologic dose/interval was sufficient to afford a tight control of inflammation and could in theory even be de-escalated.33, 34 Because fecal marker levels change during the therapeutic interval in most patients, individual single-point values should be interpreted in the context of their timing of testing in relation to drug administration. For example, a normal value immediately before infusion/injection is more suggestive of deep remission than a normal value immediately after drug administration.
The fecal marker time sensitivity to drug-induced changes in inflammation was confirmed and leveraged in the group of patients with suspected LOR. In these patients, FL measured immediately before and immediately after infusion/injection distinguished 3 groups of patients: one group had normal FL levels that remained normal after drug administration (responders), another group had elevated FL levels that partly decreased after infusion/injection but remained well above the normal threshold (partial responders), and a third group showed an increase in FL levels after drug administration (nonresponders). The increase in FL after infusion/injection in the latter group was expected because in the absence of therapeutic response, inflammation would continue to increase with time. The first group was managed conservatively, and a cause other than LOR for the apparent flare was actively sought (and found) in most of the patients (eg, hemorrhoids causing rectal bleeding). In nonresponders the medication was switched or surgery was performed for multiple biologic failures, with excellent clinical results at the 3-month follow-up time. In partial responders the therapeutic interval was decreased, with reinduction of clinical remission in most patients at 3 months. Furthermore, in the latter 2 groups the 3-month FL (performed at the end of the new drug/new therapeutic interval) dropped on average by 88% and 97%, respectively.
The average total follow-up time in the 3 groups of patients was 20 months (range, 4-48 months) during which most patients in each group continued to be successfully managed with the strategy adopted at the time of disease flare. However, 1 patient among the nonresponders and 1 patient among the partial responders developed resistance to the new medication. More important, 4 patients among the nonresponders needed surgery, as opposed to none in the other groups. Multiple biologic failures over time were more common among nonresponders4 than among partial responders and responders (1 and 0, respectively). This result suggests that biologic failures identify a group of difficult-to-treat patients: those more likely to undergo surgery.
The main limitation of our study is its retrospective nature, reflecting the clinical practice and strategies applied in our center. The patient population studied here was diverse in terms of disease type, location and extent, medications and routes used (intravenous vs subcutaneous), length of therapeutic interval, and previous biologic use. However, such heterogeneity is actually one of the strengths of the study, confirming that this strategy is applicable across the entire spectrum of disease expression and biologic therapies, a crucial feature for its practical routine use. However, adopting this strategy may be challenging if the disease only involves a short small bowel segment, when fecal marker levels may not be always elevated.35 Nevertheless, as shown herein, any baseline FL level significantly above normal may be the only prerequisite to apply this strategy.
Notably, in patients experiencing a possible flare, steroids or any other effective fast-acting medications given after symptom onset and before/during the double FL testing could affect the results. In our patients no concomitant medications were given in this period. If clinically needed (ie, patients experiencing symptoms several weeks before the next drug infusion/injection), steroids could be initiated and kept on a stable dose well before and after the double FL testing—an approach that is classically used in clinical trials.
Finally, TL and ADA could have added insightful information to the study, but they were not determined. Future prospective studies should compare TDM to the strategy proposed here—in terms of both accuracy and costs—and to endoscopy and symptom-based management. They should also clarify whether FL should be tested at different times according to the rate of drug concentration decline during the therapeutic interval, identify potential FL cutoff levels in different scenarios, and clarify whether FC could be used in place of FL.
CONCLUSIONS
The timely sensitivity of FL to drug-generated changes in inflammation provides the rationale for an accurate and inexpensive stool marker–based strategy to manage LOR. Larger, prospective studies may be needed to confirm our findings and evaluate any potential complementary role for TDM.36
SUPPLEMENTARY DATA
Supplementary data are available at Inflammatory Bowel Diseases online.
Supplementary Figure 1. FL changes during the therapeutic interval in patients with IBD treated with biologics: line graph connecting individual patient values (represented by the same color).
izaa348_suppl_Supplementary_Figure_1 Click here for additional data file.
izaa348_suppl_Supplementary_Figure_legend Click here for additional data file.
ACKNOWLEDGMENTS
We thank Dr. Kim Love for help with data analysis and James Boone for critically reviewing the manuscript.
Presented at: This study was presented in abstract form in Gastroenterology in the proceedings of Digestive Disease Week 2020, Chicago, IL.
Conflicts of interest: Dario Sorrentino has received consulting fees from Abbott/AbbVie, Schering-Plough, MSD, Janssen Research & Development LLC, Centocor Inc., TechLab, Hoffmann-LaRoche, Giuliani, Schering-Plough, and Ferring; research grants from AbbVie, Janssen Research & Development LLC, Schering-Plough, TechLab, Centocor, Takeda, Medtronic, the Broad Foundation, and the Helmsley Foundation; and serves on the speakers bureau of AbbVie and the national faculty of Janssen. | ONCE EVERY 8 WEEKS | DrugDosageText | CC BY-NC | 33501943 | 20,517,964 | 2021-07-27 |
Give an alphabetized list of all active substances of drugs taken by the patient who experienced 'Hepatitis B'. | Evaluation of Ruxolitinib for Steroid-Refractory Chronic Graft-vs-Host Disease After Allogeneic Hematopoietic Stem Cell Transplantation.
Ruxolitinib, a selective inhibitor of the Janus kinases 1/2 signaling pathway, has shown a significant response in steroid-refractory chronic graft-vs-host disease (SR-cGVHD), a major cause of morbidity and mortality in individuals who have undergone allogeneic hematopoietic stem cell transplantation (HSCT).
To investigate the clinical response to ruxolitinib in patients with SR-cGVHD after allogeneic HSCT and to evaluate its safety profile during the treatment course.
This single-center case series included 41 consecutive patients who were treated with ruxolitinib for SR-cGVHD after allogeneic HSCT between August 2017 and December 2019. Data were collected from each patient's medical record at the First Affiliated Hospital of Zhejiang University School of Medicine. Data analysis was conducted from March to May 2020.
Ruxolitinib.
Treatment responses, factors associated with response, and adverse effects during ruxolitinib administration.
Overall, 41 patients (median [range] age, 31 [17-56] years; 14 [34.1%] women) were treated with ruxolitinib and included in this study. A total of 15 patients (36.6%) had a complete remission, and 14 (34.1%) had a partial remission, with an overall response rate of 70.7% (29 patients; 95% CI, 56.2%-85.3%). Lung involvement (odds ratio, 0.112; 95% CI, 0.020-0.639; P = .01) and matched related donors (odds ratio, 0.149; 95% CI, 0.022-0.981; P = .048) were associated with less favorable treatment response. Major adverse events associated with ruxolitinib were cytopenias and infectious complications. The median (range) follow-up for this cohort was 14.9 (1.4-32.5) months. Prolonged survival was observed in patients with a male donor (P = .006), complete remission before transplantation (P = .02), baseline moderate cGVHD (P = .02), and skin cGVHD (P = .001).
In this small, single-site case series, ruxolitinib demonstrated a significant response in heavily pretreated patients with SR-cGVHD and a reasonably well-tolerated safety profile. The results add to the body of literature suggesting ruxolitinib as a promising treatment option in SR-cGVHD.
Introduction
Chronic graft-vs-host disease (cGVHD) is the leading cause of late morbidity and mortality as well as impaired quality of life after allogeneic hematopoietic stem cell transplantation (HSCT).1 Despite the use of standard prophylaxis, 35% to 70% of recipients develop cGVHD.2 Established first-line therapy for cGVHD still comprises corticosteroids and calcineurin inhibitors.3 Approximately half of patients with cGVHD are refractory to corticosteroid therapy. For various second-line therapies or interventions, the response rates range from 30% to 60%,4,5 and no consensus has been reached regarding the optimal salvage treatment for steroid-refractory (SR)–cGVHD. Therefore, it is essential to identify a promising therapeutic drug for the adequate therapy of SR-cGVHD.
There is preclinical evidence that the pharmacologic inhibition of Janus kinases 1/2 (JAK1/J2) prevents GVHD by blocking interferon-γ receptor and interleukin 6 receptor signaling. JAK1/2 inhibition does not impair donor T-cell alloreactivity. It preserves the beneficial graft vs leukemia effect in vivo, suggesting a potential role for the selective JAK1/2 inhibitor ruxolitinib in the prevention and treatment of GVHD.6,7
A multicenter retrospective study in centers throughout Europe and the United States first established the feasibility of ruxolitinib for SR–acute GVHD (aGVHD) treatment.8 Thereafter, the Ruxolitinib for the Treatment of Steroid-Refractory Acute GVHD (REACH-1) study9 investigated ruxolitinib in treating SR-aGVHD and showed that the overall response rate (ORR) on day 28 was 54.9%. This was the first time such a study was conducted prospectively, and it shed light on later randomized clinical trials.9 Subsequently, a prospective study showed that combining ruxolitinib with another agent could achieve higher ORRs.10
At present, there is no standard of care for treating SR-cGVHD because of a lack of available and substantial data from prospective studies. The efficacy of ruxolitinib vs current best available therapy in SR-cGVHD is being evaluated in an ongoing phase 3 trial (REACH-3; NCT03112603).
Based on the limited preclinical and clinical outcomes of ruxolitinib in GVHD published to date, the present study investigated the clinical response to ruxolitinib and its safety profile in patients with SR-cGVHD after allogeneic HSCT. The study aimed to provide informative data for SR-cGVHD management and to measure the benefits and risks for different patient groups.
Methods
This retrospective, single-center case series included 41 consecutive patients who were treated with ruxolitinib for SR-cGVHD after allogeneic HSCT between August 2017 and December 2019 at the First Affiliated Hospital of Zhejiang University School of Medicine. Informed consent was obtained from all recruited patients before ruxolitinib treatment and data collection. For safety and response evaluation, all data were collected from clinical history at the First Affiliated Hospital of Zhejiang University School of Medicine. The study was reviewed and approved by the ethics committee of the First Affiliated Hospital of Zhejiang University School of Medicine. This study followed the reporting guideline for case series.
All patients were aged 10 years or older and were successfully engrafted with full donor chimerism. Patients undergoing allogeneic HSCT, diagnosed with moderate or severe cGVHD, and refractory to steroid-based therapy were included. cGVHD was defined and graded following the National Institutes of Health (NIH) criteria or confirmed biopsy. SR was defined as cGVHD worsening on prednisone of at least 1 mg/kg/d for 1 to 2 weeks or sustained use of prednisone of a least 0.5 mg/kg/d (or 1 mg/kg every other day) for at least 4 weeks.11
Enrolled patients received ruxolitinib orally. Normally, a patient weighing 60 kg or less received a dose of 5 mg twice daily; patients weighing more than 60 kg received 10 mg twice a day. Patients with grade 3 cytopenia (according to National Cancer Institute–Common Terminology Criteria for Adverse Events [NCI-CTCAE] version 4.0) received 5 mg once a day. If patients presented worsening cGVHD according to NIH criteria within 4 weeks after administration, ruxolitinib would be withdrawn.
Response evaluation was conducted according to clinical status in the sixth month after the first ruxolitinib administration. The ORR included complete response (CR) and partial response (PR). CR was defined as the absence of all manifestations of cGVHD; PR was defined as an improvement in cGVHD compared with baseline clinical status and stage according to the NIH consensus and without any progression in any organs or sites. Other situations, including stable disease (SD), defined as no changes, and progressive disease (PD), defined as worsening in at least 1 site or organ, were categorized as treatment failure; discontinuation because of toxic effects from ruxolitinib was not included.
We collected and analyzed the following data: (1) adverse events, such as infections and cytopenia based on NCI-CTCAE version 4.0, were clinically relevant as grade 2 or higher; (2) time to response, defined as the initial use of ruxolitinib to initial response; (3) nonrelapsed mortality (NRM), which was defined as the initial treatment of ruxolitinib until death from any cause except underlying malignant neoplasm relapse or recurrence; (4) overall survival (OS), which was defined as the initial treatment of ruxolitinib until death from any cause; (5) cumulative incidence of cGVHD flare, which was defined as the initial use of ruxolitinib until cGVHD progression; and (6) the cumulative relapse of underlying malignant neoplasm, which was defined as the initial use of ruxolitinib until the first relapse. Patients who were lost to the last follow-up were censored.
Statistical Analysis
Data were analyzed using SPSS statistical software version 22.0.01 (IBM Corp). A 2-tailed P < .05 was considered statistically significant. Univariate comparisons of parameters were performed using the χ2 test, Fisher exact test, and t test, as appropriate. Variables with P < .20 in univariate analysis were entered into the multivariate model. OS was estimated and plotted using the Kaplan-Meier method. The log-rank test was applied to compare Kaplan-Meier curves. The proportional-hazards method was used to estimate the cumulative incidence of relapse and NRM. Relapse and NRM were competing risks for each other. R statistical software version 3.4.3 (R Project for Statistical Computing) was used for the competing risk analysis.
Results
Patients
Between August 2017 and December 2019, 41 patients with SR-cGVHD, with a median (range) age of 31 (17-56) years and 14 (34.1%) women, were treated with ruxolitinib and included in this study. The demographic and baseline characteristics of the 41 participants are summarized in Table 1. Acute lymphoid leukemia (18 [43.9%]) and acute myeloid leukemia (17 [41.5%]) were the 2 most common diagnoses. All peripheral blood stem cells were obtained from related donors, including 9 patients (22.0%) receiving human leukocyte antigen (HLA)–matched grafts and 32 patients (78.0%) receiving HLA-haploidentical grafts. Only 1 patient (2.4%) underwent reduced-intensity conditioning, and antithymocyte globulin was administrated to the 32 patients (78.0%) receiving HLA-haploidentical transplantation (Table 1).
Table 1. Patient, Donor, and Transplant Characteristics
Characteristic No. (%)
Patient age, median (range), y 31 (17-56)
Men 27 (65.9)
Male donor 20 (48.8)
Haploidentical donor 32 (78.0)
HLA-matched relative 9 (22.0)
Donor-recipient gender
FF 9 (22.0)
MM 19 (46.3)
FM 10 (24.4)
MF 3 (7.3)
Stem cell source
PBSC 41 (100)
Diagnosis
ALL 18 (43.9)
AML 17 (41.5)
Other 6 (14.6)
Disease status at transplant
CR 37 (90.2)
PR 2 (4.9)
Progressive 2 (4.8)
Conditioning regimen
MAC 40 (97.6)
RIC 1 (2.4)
Use of ATG
Yes 32 (78.0)
No 9 (22.0)
Prior acute graft-vs-host disease
No 8 (19.5)
Grade I to II 21 (51.2)
Grade III to IV 12 (29.3)
Abbreviations: ALL, acute lymphoid leukemia; AML, acute myeloid leukemia; ATG, antithymoglobuline; CR, complete remission; FF, female to female; FM, female to male; HLA, human leukocyte antigen; MAC, myeloablative conditioning; MF, male to female; MM, male to male; PBSC, peripheral blood stem cell; PR, partial remission; RIC, reduced intensity conditioning.
A total of 32 patients (78.0%) developed prior aGVHD, with grade I (11 [34.4%]), grade II (10 [24.4%]), grade III (8 [25.0%]), and grade IV (4 [12.5%]). The median (range) time from HSCT to cGVHD diagnosis was 9.0 (3.3-27.2) months. Two patients (4.9%) showing overlap syndrome were enrolled in the study. At the time of enrollment, 27 patients (65.9%) had severe cGVHD, and 14 patients (34.1%) had moderate cGVHD. Organ involvement included skin (28 [68.3%]), mouth (29 [70.7%]), lungs (18 [43.9%]), liver (15 [36.6%]), eyes (14 [34.1%]), musculoskeleton (9 [22.0%]), kidney (3 [7.3%]), genitalia (3 [7.3%]), gastrointestinal tract (2 [4.9%]), eosinophilia (2 [4.9%]), nails (2 [4.9%]), and others (3 [7.3%]) (Table 2). More than half of patients (24 [58.5%]) had more than 2 sites or organs involved. No patient received posttransplant cyclophosphamide as GVHD prophylaxis.
Table 2. Characteristics of cGVHD
Characteristic No. (%,)
Time from transplantation to cGVHD, median (range), mo 9.0 (3.3-27.2)
Overlap syndrome 2 (4.9)
Severe NIH score 27 (65.9)
Moderate NIH score 14 (34.1)
Organ affected
Skin 28 (68.3)
Mouth 29 (70.7)
Lungs 18 (43.9)
Liver 15 (36.6)
Eyes 14 (34.1)
Joint and fascia 9 (22.0)
Genitalia 3 (7.3)
Kidney 3 (7.3)
Gastrointestinal tract 2 (4.9)
Nails 2 (4.9)
Involved sites
1 6 (14.6)
2 11 (26.8)
3 13 (31.7)
4 5 (12.2)
>4 6 (14.6)
Previous second-line agents, median (range) 3 (1-6)
Previous agents
Tacrolimus 36 (87.8)
Mycophenolate mofetil 26 (65.0)
Imatinib 15 (36.6)
CsA 15 (36.6)
Methotrexate 12 (29.3)
Mesenchymal stem cells 9 (22.0)
Infliximab 7 (17.1)
Others 10 (24.3)
Time from cGVHD to initial ruxolitinib treatment, median (range), mo 11.0 (0.6-71.9)
Abbreviations: CsA, cyclosporine A; cGVHD, chronic graft-vs-host disease; NIH, National Institutes of Health.
The median (range) number of second-line immunosuppressive agents before ruxolitinib was 3 (1-6). Tacrolimus (36 [87.8%]) and mycophenolate mofetil (26 [65.0%]) were the most commonly used agents. Ruxolitinib was started at a median (range) of 11.0 (0.6-71.9) months after the diagnosis of cGVHD (Table 2).
Response, Outcomes, and Long-term Survival
After a median (range) duration of 7.5 (1.0-24.9) months of ruxolitinib treatment, the ORR at 6 months was 70.7% (29 of 41 patients), including 15 patients (36.6%) with CR and 14 patients (34.1%) with PR. Among 12 patients (29.3%) with treatment failure, 5 (41.7%) had SD and 7 (58.3%) had PD (Figure 1A). The median (range) time to response was 2 (0.5-6.0) months. Ruxolitinib treatment was continued for a median (range) of 8.6 (1.1-24.9) months in those who responded. Patients with moderate cGVHD and those with severe cGVHD had similar ORRs (12 of 14 [85.7%] vs 17 of 27 [63.0%]; P = .17) and time to response (median [range], 2.3 [0.5-6.0] months vs 2.0 [1.0-6.0] months; P = .66). The number of involved organs was not associated with ORR or the time to response. There was no significant difference between patients who responded vs those who did not regarding previous lines of second-line agents (median [range], 4 [1-5] vs 3 [1-6]; P = .60) or time from cGVHD diagnosis to receiving ruxolitinib (median [range], 9.0 [0.6-71.9] months vs 14.1 [1.7-67.4] months; P = .89). Seven patients (17.1%) had ruxolitinib duration of less than 6 months because of death events (4 patients [57.1%]) and self-withdrawal due to favorable responses (3 patients [42.9%]). Compared with patients without lung cGVHD, the global ORR of those with lung involvement was relatively low (20 of 23 [87.0%] vs 9 of 18 [50.0%], P = .01). The ORR was 22 of 28 (78.6%) in the skin, 22 of 29 (75.9%) in the mouth, 8 of 14 (57.1%) in eyes, 2 of 2 (100%) in the gastrointestinal tract, 12 of 15 (80.0%) in the liver, 9 of 18 (50.0%) in the lungs, 5 of 9 (55.6%) in the musculoskeleton, and 1 of 3 (33.3%) in genitalia (Figure 1B). In this cohort, 18 patients (43.9%) discontinued ruxolitinib administration because of treatment failure (11 [61.1%]), relapse of underlying malignant neoplasm (6 [33.3%]), and lung infection (1 [5.6%]).
Figure 1. Treatment Response and Prednisone Dose Among 41 Patients with Steroid-Refractory Chronic Graft-vs-Host Disease (cGVHD)
Median (range) treatment duration was 8.6 (1.1-24.9) months in responders. CR indicates complete remission; GI, gastrointestinal tract; PD, progressive disease; PR, partial remission; and SD, stable disease.
Variables with P < .20 in the univariate analysis were included in the later multivariate analysis. These were donor sex, recipient sex, donor type, history of donor lymphocyte infusion, cGVHD severity, lung involvement, and skin involvement. The logistic regression demonstrated that matched related donors (odds ratio [OR], 0.149; 95% CI, 0.022-0.981; P = .048) and lung cGVHD (OR, 0.112; 95% CI, 0.020-0.639; P = .01) were associated with treatment failure (Figure 1C). Although lacking statistical significance, the haploidentical HSCT group had higher ORR than the matched-related HSCT group (25 of 32 [71.4%] vs 4 of 9 [44.4%]; P = .09). There was no significant difference between the haploidentical group and the matched group in cGVHD baseline, including cGVHD severity (severe cGVHD: 19 [59.3%] vs 8 [88.9%]; P = .13), number of previous second-line drugs (median [range], 3 [1-6] vs 3 [2-5]; P = .28), duration of cGVHD course (median [range], 9.6 [0.6-71.9] months vs 16.4 [1.0-44.0] months; P = .90), or involved organs (skin: 24 [75.0%] vs 4 [44.4%]; P = .11; mouth: 22 [68.8%] vs 7 [77.8%]; P = .70; lung: 14 [43.8%] vs 4 [44.4%]; P > .99; liver: 11 [34.3%] vs 4 [44.4%]; P = .70; eyes: 9 [28.1%] vs 5 [55.6%]; P = .23; joint and fascia: 6 [18.8%] vs 3 [33.3%]; P = .38).
Furthermore, 26 of 29 patients who responded and 4 of 5 patients with SD (30 of 34 [88.2%]) received concomitant prednisone at a median (range) dose of 15 (2.5-45) mg/d without any dose alteration within 2 weeks before the first administration of ruxolitinib. At the last dose of ruxolitinib, prednisone reduction occurred in 27 patients (90.0%) at a median (range) dose of 10 (0-20) mg/d, with a median (range) reduction of 50.0% (33.3%-100%). Of these 27 patients, dose was decreased for 19 (63.3%) and discontinued for 8 (26.7%). The median (range) dose of concomitant prednisone at 3 months, 6 months, and 12 months was 15 (0-35) mg/d, 10 (0-15) mg/d, and 7.5 (0-10) mg/d, respectively (Figure 1D).
In 23 patients (56.1%) receiving concomitant second-line immunosuppressive agents, including 2 patients with SD and 21 who responded, dosage reduction and discontinuation were observed in 15 patients (65.2%) and 6 patients (26.1%), respectively. Only 2 of 14 patients (14.3%) with PR continued tacrolimus with the same dose for maintenance.
The 6-month and 12-month OS rates for all treated patients were 87.8% (95% CI, 77.3%-98.3%) and 65.9% (95% CI, 50.7%-81.0%), respectively (Figure 2A). The median (range) follow-up was 14.9 (1.4-32.5) months. The univariate analysis showed that patients with a male donor (P = .006), complete remission before transplantation (P = .02), baseline moderate cGVHD (P = .02), and skin cGVHD (P = .001) might achieve prolonged survival (Figure 3). Grafts from a male donor were more likely to have skin cGVHD (18 of 20 [90.0%] vs 10 of 21 [47.6%]; P = .009), and most matched related donors were women (8 of 12 [66.7%] vs 1 of 20 [5.0%]; P = .02).
Figure 2. Overall Survival, Relapse Incidence, and Cumulative Flare Incidence During the Follow-up Period
cGVHD indicates chronic graft-vs-host disease; NRM indicates nonrelapsed mortality.
Figure 3. Survival Probabilities
cGVHD indicates chronic graft-vs-host disease; CR indicates complete remission; and HSCT indicates hematopoietic stem cell transplantation.
Safety Profile
All adverse effects occurring after ruxolitinib administration were documented (eTable in the Supplement). The prophylaxis against infection, including sulfamethoxazole for pneumocystis pneumonia and micafungin or posaconazole for invasive fungal disease, was provided for all patients. Eleven patients (26.8%; 6 [54.5%] with response and 5 [45.5%] with no response) experienced lung infection during ruxolitinib treatment, and 3 patients (27.3%) died due to the infection. Patients with lung involvement were more likely to develop lung infection (8 of 18 [44.4%] vs 3 of 23 [13.0%]; P = .04).
Cytomegalovirus (CMV) detection before and after the use of ruxolitinib was performed for 34 patients (82.9%), of whom 5 patients (14.7%) underwent CMV DNAemia. Similarly, Epstein-Barr virus (EBV) data for 7 patients were unavailable, and 19 of 36 patients (52.7%) experienced EBV DNAemia after ruxolitinib administration. Two patients (4.9%) and 1 patient (2.4%) had carbapenem-resistant Klebsiella pneumoniae sepsis and hepatitis B (HBV) reaction, respectively.
Cytopenias were reported during ruxolitinib treatment in 6 patients (14.6%), of which 3 (50.0%) were of grades 3 to 4, including 1 grade 4 thrombocytopenia and 2 grade 3 leukocytopenia/thrombocytopenia. In 1 patient (16.7%), thrombocytopenia was related to the use of sulfamethoxazole.
Eight patients (19.5%) had manifestations of necrosis of the femoral head. Overall, the recurrence of underlying malignant neoplasm was found in 6 patients (14.6%). The cumulative incidence is shown in Figure 2B. cGVHD flare was observed in 9 of 29 patients (31.0%) with response due to drug discontinuation, presenting mild cGVHD manifestations (Figure 2C). These patients had cGVHD flare in their previously involved organs, including mouth, skin, musculoskeleton, and kidney. Four patients (44.4%) with cGVHD flare restarted ruxolitinib and regained initial responses. Overall, 9 patients died (22.0%) due to relapse of the primary malignancy (5 [55.6%]), pneumonia (3 [33.3%]; Pneumocystis jiroveci pneumonia, invasive fungal disease, and fungal/bacteria mixed infection), and acute liver failure caused by HBV reaction (1 [11.1%]).
The 1-year and 2-year NRM rates were 8.6% and 12.5%, respectively. The 1-year and 2-year cumulative incidences of relapse were 10.6% and 17.1%, respectively (Figure 2B).
Discussion
The treatment strategies for patients with SR-cGVHD have changed. Multiple immunosuppressive agents provide clinicians with new approaches for treating patients with SR-cGVHD with few guidelines and a lack of consensus. Previous studies showed that the ORR of ruxolitinib in refractory cGVHD treatment was approximately 43.5% to 100%, and the CRR was from 3.5% to 13.0%, with a median time to best response ranging from 2 to 4 weeks.8,12,13,14 In the present study, the ORR was 70.7% (95% CI, 56.2%-85.3%), and the CRR was 36.6% (95% CI, 21.2%-52.0%). The median time to reach the best response was 2.0 months.
Ruxolitinib showed potential to resolve cGVHD. This study found that compared with patients with moderate cGVHD and less organ involvement, patients with severe and multiple involved organs had similar treatment outcome in terms of not only ORR but also the time to achieve response. Importantly, the treatment response showed no significant difference in patients with different previous lines of second-line agents and the time from cGVHD diagnosis to receiving ruxolitinib. The aforementioned scenario might suggest the use of ruxolitinib in patients with cGVHD regardless of cGVHD severity, the numbers of involved organs, the duration of cGVHD course, or the intensity of previous pharmacological therapies.
A primary aim of this study was to examine the factors associated with treatment response for ruxolitinib. The statistical results showed an association between lung cGVHD and treatment response, which was also reported in a previous study.13 The multivariate analysis indicated that among patients with cGVHD, lung involvement was associated with a higher risk of treatment failure.
The underlying mechanism of this association has not yet been elucidated. However, ensuing pulmonary fibrosis, symbolized with myofibroblast hyperplasia, is promoted by macrophages, B-cells, and complicated networks of other cells.15 A 3-phase model was developed for cGVHD in which the third phase is hypothesized to be due to the excessive accumulation of extracellular matrix, causing abnormal fibrosis.16
For example, interleukin 21 (IL-21) promotes the differentiation of B-cells into plasma cells via the JAK/signal transducer and activator of transcription 3 (STAT3) pathway, leading to antibody secretion and deposition.17 As an inhibitor of JAK-STAT signaling, ruxolitinib interferes with the activation and differentiation of T-cells and suppresses the activity of macrophages.18 However, the efficacy of ruxolitinib is not evident when it comes to the irreversible third phase, which is characterized by aberrant depositions and fibrosis. This explains the less effective results of ruxolitinib in lung cGVHD. In addition to treatment response, patients with lung cGVHD were more likely to develop pulmonary infection than patients with other types of cGVHD (8 of 18 [44.4%] vs 3 of 23 [13.0%]; P = .04). As such, patients without lung involvement were more likely to benefit from ruxolitinib. However, even the lungs could achieve a promising ORR of 50.0% in terms of difficulties in treating lung cGVHD. The ORR of other organs was similar, indicating that the pharmacokinetics of ruxolitinib could enable the distribution of the drug in target sites.
In this cohort, there was no significant difference between the haploidentical group and the matched group in cGVHD baseline, including cGVHD severity, number of previous second-line drugs, duration of cGVHD course, and involved organs. However, it is interesting to note that patients receiving haploidentical HSCT were observed to have higher ORR than those with matched related donors. Although JAK regulates the function of panoramic immune cells such as T-cells, B-cells, macrophages, and dendritic cells,7,19,20,21correlating with the etiology of cGVHD, the different treatment responses might underlie the heterogeneous pathogenesis of cGVHD between patients receiving stem cells from haploidentical and matched related donors. Currently, cGVHD is considered an entity, tantamount to an autoimmune disorder, with few comparisons in recipients receiving haploidentical and matched grafts. Thus, the potential disparities in the pathogenesis of cGVHD remain to be explored.
The cohort showed that male donors, CR before transplantation, skin cGVHD, and moderate cGVHD were associated with prolonged survival. This study found that patients receiving peripheral blood stem cells (PBSC) from male donors had more skin cGVHD events.
The estimated OS was compared between patients with and without a response. That the estimated OS plots were similar might ignore the fact that patients who responded had a higher quality of life, without or with fewer cGVHD events. A recent study demonstrated that the development of cGVHD was not associated with OS.22 In other words, survival time was comparatively fixed despite the resolution of cGVHD with the treatment of ruxolitinib. In this study, 23 patients had infections, including 11 with lung infection, 5 with CMV DNAemia, 19 with EBV DNAemia, 2 with sepsis, and 1 with HBV reaction. The latest REACH-1 study9 on aGVHD showed that infection events during ruxolitinib were approximately 80.3%, of which CMV events were the most common (19.7%). Zeiser et al8 found that the incidence of CMV events was higher in SR-aGVHD than in SR-cGVHD (33.3% vs 14.6%). Collectively, infection in patients with SR-cGVHD was tolerated, but 4 of 9 patients died of infection-related complications, highlighting the importance of antibacterial, antifungal, and antiviral prophylaxis.
Regarding cytopenia, the most common adverse effects related to ruxolitinib in the REACH-1 study were anemia (35.2%), thrombocytopenia (32.4%), and neutropenia (26.8%). The study by Zeiser et al8 showed that 5 patients with SR-aGVHD were more likely to develop global cytopenias and severe cytopenias compared with patients with cGVHD during the ruxolitinib course. The overall frequency of cytopenias in this study was only 14.6%, and grade 3 to 4 cytopenia occurred in 3 cases (7.3%), which was lower than the values reported in the study by Zeiser et al8 on the use of ruxolitinib in cGVHD and aGVHD.
Limitations
This study has limitations. First, this single-center study lacked sufficient participants and death events to perform a multivariate analysis. For example, we found no statistical significance of OS between patients who did and did not respond. The limited data size dramatically interfered with the P value, which might lead to nonsignificant results, and patients from a single center might contribute to survival bias. It is important to emphasize that because of the study’s observational and retrospective nature, the results should be interpreted with caution. Second, some results failed to provide key insights. While we found patients with haploidentical donors might receive more benefit from ruxolitinib compared with matched related donors, the underlying mechanism for this phenomenon remains unclear. Third, although we highlight that ruxolitinib as a single agent could lower expenditure, we could not measure the actual costs of ruxolitinib regarding its dosage and course of treatment.
Conclusions
This case series found that ruxolitinib in patients with SR-cGVHD had an ORR of 70.7% and CRR of 36.6%. Nearly all patients reduced the dose or discontinued the use of concomitant corticosteroids and other immunosuppressive drugs, minimizing their side effects and cost burden. Despite the limited sample size and retrospective nature, the results of this study indicated that patients with no lung involvement and haploidentical relatives as donors were more likely to benefit from ruxolitinib. Regarding the safety profile, the present study showed that infection events were the most severe adverse effect related to ruxolitinib, highlighting the significance of infection prophylaxis.
Supplement. eTable. Safety Profile of Ruxolitinib
Click here for additional data file. | RUXOLITINIB | DrugsGivenReaction | CC BY | 33502484 | 19,019,953 | 2021-01-04 |
Give an alphabetized list of all active substances of drugs taken by the patient who experienced 'Product use in unapproved indication'. | Evaluation of Ruxolitinib for Steroid-Refractory Chronic Graft-vs-Host Disease After Allogeneic Hematopoietic Stem Cell Transplantation.
Ruxolitinib, a selective inhibitor of the Janus kinases 1/2 signaling pathway, has shown a significant response in steroid-refractory chronic graft-vs-host disease (SR-cGVHD), a major cause of morbidity and mortality in individuals who have undergone allogeneic hematopoietic stem cell transplantation (HSCT).
To investigate the clinical response to ruxolitinib in patients with SR-cGVHD after allogeneic HSCT and to evaluate its safety profile during the treatment course.
This single-center case series included 41 consecutive patients who were treated with ruxolitinib for SR-cGVHD after allogeneic HSCT between August 2017 and December 2019. Data were collected from each patient's medical record at the First Affiliated Hospital of Zhejiang University School of Medicine. Data analysis was conducted from March to May 2020.
Ruxolitinib.
Treatment responses, factors associated with response, and adverse effects during ruxolitinib administration.
Overall, 41 patients (median [range] age, 31 [17-56] years; 14 [34.1%] women) were treated with ruxolitinib and included in this study. A total of 15 patients (36.6%) had a complete remission, and 14 (34.1%) had a partial remission, with an overall response rate of 70.7% (29 patients; 95% CI, 56.2%-85.3%). Lung involvement (odds ratio, 0.112; 95% CI, 0.020-0.639; P = .01) and matched related donors (odds ratio, 0.149; 95% CI, 0.022-0.981; P = .048) were associated with less favorable treatment response. Major adverse events associated with ruxolitinib were cytopenias and infectious complications. The median (range) follow-up for this cohort was 14.9 (1.4-32.5) months. Prolonged survival was observed in patients with a male donor (P = .006), complete remission before transplantation (P = .02), baseline moderate cGVHD (P = .02), and skin cGVHD (P = .001).
In this small, single-site case series, ruxolitinib demonstrated a significant response in heavily pretreated patients with SR-cGVHD and a reasonably well-tolerated safety profile. The results add to the body of literature suggesting ruxolitinib as a promising treatment option in SR-cGVHD.
Introduction
Chronic graft-vs-host disease (cGVHD) is the leading cause of late morbidity and mortality as well as impaired quality of life after allogeneic hematopoietic stem cell transplantation (HSCT).1 Despite the use of standard prophylaxis, 35% to 70% of recipients develop cGVHD.2 Established first-line therapy for cGVHD still comprises corticosteroids and calcineurin inhibitors.3 Approximately half of patients with cGVHD are refractory to corticosteroid therapy. For various second-line therapies or interventions, the response rates range from 30% to 60%,4,5 and no consensus has been reached regarding the optimal salvage treatment for steroid-refractory (SR)–cGVHD. Therefore, it is essential to identify a promising therapeutic drug for the adequate therapy of SR-cGVHD.
There is preclinical evidence that the pharmacologic inhibition of Janus kinases 1/2 (JAK1/J2) prevents GVHD by blocking interferon-γ receptor and interleukin 6 receptor signaling. JAK1/2 inhibition does not impair donor T-cell alloreactivity. It preserves the beneficial graft vs leukemia effect in vivo, suggesting a potential role for the selective JAK1/2 inhibitor ruxolitinib in the prevention and treatment of GVHD.6,7
A multicenter retrospective study in centers throughout Europe and the United States first established the feasibility of ruxolitinib for SR–acute GVHD (aGVHD) treatment.8 Thereafter, the Ruxolitinib for the Treatment of Steroid-Refractory Acute GVHD (REACH-1) study9 investigated ruxolitinib in treating SR-aGVHD and showed that the overall response rate (ORR) on day 28 was 54.9%. This was the first time such a study was conducted prospectively, and it shed light on later randomized clinical trials.9 Subsequently, a prospective study showed that combining ruxolitinib with another agent could achieve higher ORRs.10
At present, there is no standard of care for treating SR-cGVHD because of a lack of available and substantial data from prospective studies. The efficacy of ruxolitinib vs current best available therapy in SR-cGVHD is being evaluated in an ongoing phase 3 trial (REACH-3; NCT03112603).
Based on the limited preclinical and clinical outcomes of ruxolitinib in GVHD published to date, the present study investigated the clinical response to ruxolitinib and its safety profile in patients with SR-cGVHD after allogeneic HSCT. The study aimed to provide informative data for SR-cGVHD management and to measure the benefits and risks for different patient groups.
Methods
This retrospective, single-center case series included 41 consecutive patients who were treated with ruxolitinib for SR-cGVHD after allogeneic HSCT between August 2017 and December 2019 at the First Affiliated Hospital of Zhejiang University School of Medicine. Informed consent was obtained from all recruited patients before ruxolitinib treatment and data collection. For safety and response evaluation, all data were collected from clinical history at the First Affiliated Hospital of Zhejiang University School of Medicine. The study was reviewed and approved by the ethics committee of the First Affiliated Hospital of Zhejiang University School of Medicine. This study followed the reporting guideline for case series.
All patients were aged 10 years or older and were successfully engrafted with full donor chimerism. Patients undergoing allogeneic HSCT, diagnosed with moderate or severe cGVHD, and refractory to steroid-based therapy were included. cGVHD was defined and graded following the National Institutes of Health (NIH) criteria or confirmed biopsy. SR was defined as cGVHD worsening on prednisone of at least 1 mg/kg/d for 1 to 2 weeks or sustained use of prednisone of a least 0.5 mg/kg/d (or 1 mg/kg every other day) for at least 4 weeks.11
Enrolled patients received ruxolitinib orally. Normally, a patient weighing 60 kg or less received a dose of 5 mg twice daily; patients weighing more than 60 kg received 10 mg twice a day. Patients with grade 3 cytopenia (according to National Cancer Institute–Common Terminology Criteria for Adverse Events [NCI-CTCAE] version 4.0) received 5 mg once a day. If patients presented worsening cGVHD according to NIH criteria within 4 weeks after administration, ruxolitinib would be withdrawn.
Response evaluation was conducted according to clinical status in the sixth month after the first ruxolitinib administration. The ORR included complete response (CR) and partial response (PR). CR was defined as the absence of all manifestations of cGVHD; PR was defined as an improvement in cGVHD compared with baseline clinical status and stage according to the NIH consensus and without any progression in any organs or sites. Other situations, including stable disease (SD), defined as no changes, and progressive disease (PD), defined as worsening in at least 1 site or organ, were categorized as treatment failure; discontinuation because of toxic effects from ruxolitinib was not included.
We collected and analyzed the following data: (1) adverse events, such as infections and cytopenia based on NCI-CTCAE version 4.0, were clinically relevant as grade 2 or higher; (2) time to response, defined as the initial use of ruxolitinib to initial response; (3) nonrelapsed mortality (NRM), which was defined as the initial treatment of ruxolitinib until death from any cause except underlying malignant neoplasm relapse or recurrence; (4) overall survival (OS), which was defined as the initial treatment of ruxolitinib until death from any cause; (5) cumulative incidence of cGVHD flare, which was defined as the initial use of ruxolitinib until cGVHD progression; and (6) the cumulative relapse of underlying malignant neoplasm, which was defined as the initial use of ruxolitinib until the first relapse. Patients who were lost to the last follow-up were censored.
Statistical Analysis
Data were analyzed using SPSS statistical software version 22.0.01 (IBM Corp). A 2-tailed P < .05 was considered statistically significant. Univariate comparisons of parameters were performed using the χ2 test, Fisher exact test, and t test, as appropriate. Variables with P < .20 in univariate analysis were entered into the multivariate model. OS was estimated and plotted using the Kaplan-Meier method. The log-rank test was applied to compare Kaplan-Meier curves. The proportional-hazards method was used to estimate the cumulative incidence of relapse and NRM. Relapse and NRM were competing risks for each other. R statistical software version 3.4.3 (R Project for Statistical Computing) was used for the competing risk analysis.
Results
Patients
Between August 2017 and December 2019, 41 patients with SR-cGVHD, with a median (range) age of 31 (17-56) years and 14 (34.1%) women, were treated with ruxolitinib and included in this study. The demographic and baseline characteristics of the 41 participants are summarized in Table 1. Acute lymphoid leukemia (18 [43.9%]) and acute myeloid leukemia (17 [41.5%]) were the 2 most common diagnoses. All peripheral blood stem cells were obtained from related donors, including 9 patients (22.0%) receiving human leukocyte antigen (HLA)–matched grafts and 32 patients (78.0%) receiving HLA-haploidentical grafts. Only 1 patient (2.4%) underwent reduced-intensity conditioning, and antithymocyte globulin was administrated to the 32 patients (78.0%) receiving HLA-haploidentical transplantation (Table 1).
Table 1. Patient, Donor, and Transplant Characteristics
Characteristic No. (%)
Patient age, median (range), y 31 (17-56)
Men 27 (65.9)
Male donor 20 (48.8)
Haploidentical donor 32 (78.0)
HLA-matched relative 9 (22.0)
Donor-recipient gender
FF 9 (22.0)
MM 19 (46.3)
FM 10 (24.4)
MF 3 (7.3)
Stem cell source
PBSC 41 (100)
Diagnosis
ALL 18 (43.9)
AML 17 (41.5)
Other 6 (14.6)
Disease status at transplant
CR 37 (90.2)
PR 2 (4.9)
Progressive 2 (4.8)
Conditioning regimen
MAC 40 (97.6)
RIC 1 (2.4)
Use of ATG
Yes 32 (78.0)
No 9 (22.0)
Prior acute graft-vs-host disease
No 8 (19.5)
Grade I to II 21 (51.2)
Grade III to IV 12 (29.3)
Abbreviations: ALL, acute lymphoid leukemia; AML, acute myeloid leukemia; ATG, antithymoglobuline; CR, complete remission; FF, female to female; FM, female to male; HLA, human leukocyte antigen; MAC, myeloablative conditioning; MF, male to female; MM, male to male; PBSC, peripheral blood stem cell; PR, partial remission; RIC, reduced intensity conditioning.
A total of 32 patients (78.0%) developed prior aGVHD, with grade I (11 [34.4%]), grade II (10 [24.4%]), grade III (8 [25.0%]), and grade IV (4 [12.5%]). The median (range) time from HSCT to cGVHD diagnosis was 9.0 (3.3-27.2) months. Two patients (4.9%) showing overlap syndrome were enrolled in the study. At the time of enrollment, 27 patients (65.9%) had severe cGVHD, and 14 patients (34.1%) had moderate cGVHD. Organ involvement included skin (28 [68.3%]), mouth (29 [70.7%]), lungs (18 [43.9%]), liver (15 [36.6%]), eyes (14 [34.1%]), musculoskeleton (9 [22.0%]), kidney (3 [7.3%]), genitalia (3 [7.3%]), gastrointestinal tract (2 [4.9%]), eosinophilia (2 [4.9%]), nails (2 [4.9%]), and others (3 [7.3%]) (Table 2). More than half of patients (24 [58.5%]) had more than 2 sites or organs involved. No patient received posttransplant cyclophosphamide as GVHD prophylaxis.
Table 2. Characteristics of cGVHD
Characteristic No. (%,)
Time from transplantation to cGVHD, median (range), mo 9.0 (3.3-27.2)
Overlap syndrome 2 (4.9)
Severe NIH score 27 (65.9)
Moderate NIH score 14 (34.1)
Organ affected
Skin 28 (68.3)
Mouth 29 (70.7)
Lungs 18 (43.9)
Liver 15 (36.6)
Eyes 14 (34.1)
Joint and fascia 9 (22.0)
Genitalia 3 (7.3)
Kidney 3 (7.3)
Gastrointestinal tract 2 (4.9)
Nails 2 (4.9)
Involved sites
1 6 (14.6)
2 11 (26.8)
3 13 (31.7)
4 5 (12.2)
>4 6 (14.6)
Previous second-line agents, median (range) 3 (1-6)
Previous agents
Tacrolimus 36 (87.8)
Mycophenolate mofetil 26 (65.0)
Imatinib 15 (36.6)
CsA 15 (36.6)
Methotrexate 12 (29.3)
Mesenchymal stem cells 9 (22.0)
Infliximab 7 (17.1)
Others 10 (24.3)
Time from cGVHD to initial ruxolitinib treatment, median (range), mo 11.0 (0.6-71.9)
Abbreviations: CsA, cyclosporine A; cGVHD, chronic graft-vs-host disease; NIH, National Institutes of Health.
The median (range) number of second-line immunosuppressive agents before ruxolitinib was 3 (1-6). Tacrolimus (36 [87.8%]) and mycophenolate mofetil (26 [65.0%]) were the most commonly used agents. Ruxolitinib was started at a median (range) of 11.0 (0.6-71.9) months after the diagnosis of cGVHD (Table 2).
Response, Outcomes, and Long-term Survival
After a median (range) duration of 7.5 (1.0-24.9) months of ruxolitinib treatment, the ORR at 6 months was 70.7% (29 of 41 patients), including 15 patients (36.6%) with CR and 14 patients (34.1%) with PR. Among 12 patients (29.3%) with treatment failure, 5 (41.7%) had SD and 7 (58.3%) had PD (Figure 1A). The median (range) time to response was 2 (0.5-6.0) months. Ruxolitinib treatment was continued for a median (range) of 8.6 (1.1-24.9) months in those who responded. Patients with moderate cGVHD and those with severe cGVHD had similar ORRs (12 of 14 [85.7%] vs 17 of 27 [63.0%]; P = .17) and time to response (median [range], 2.3 [0.5-6.0] months vs 2.0 [1.0-6.0] months; P = .66). The number of involved organs was not associated with ORR or the time to response. There was no significant difference between patients who responded vs those who did not regarding previous lines of second-line agents (median [range], 4 [1-5] vs 3 [1-6]; P = .60) or time from cGVHD diagnosis to receiving ruxolitinib (median [range], 9.0 [0.6-71.9] months vs 14.1 [1.7-67.4] months; P = .89). Seven patients (17.1%) had ruxolitinib duration of less than 6 months because of death events (4 patients [57.1%]) and self-withdrawal due to favorable responses (3 patients [42.9%]). Compared with patients without lung cGVHD, the global ORR of those with lung involvement was relatively low (20 of 23 [87.0%] vs 9 of 18 [50.0%], P = .01). The ORR was 22 of 28 (78.6%) in the skin, 22 of 29 (75.9%) in the mouth, 8 of 14 (57.1%) in eyes, 2 of 2 (100%) in the gastrointestinal tract, 12 of 15 (80.0%) in the liver, 9 of 18 (50.0%) in the lungs, 5 of 9 (55.6%) in the musculoskeleton, and 1 of 3 (33.3%) in genitalia (Figure 1B). In this cohort, 18 patients (43.9%) discontinued ruxolitinib administration because of treatment failure (11 [61.1%]), relapse of underlying malignant neoplasm (6 [33.3%]), and lung infection (1 [5.6%]).
Figure 1. Treatment Response and Prednisone Dose Among 41 Patients with Steroid-Refractory Chronic Graft-vs-Host Disease (cGVHD)
Median (range) treatment duration was 8.6 (1.1-24.9) months in responders. CR indicates complete remission; GI, gastrointestinal tract; PD, progressive disease; PR, partial remission; and SD, stable disease.
Variables with P < .20 in the univariate analysis were included in the later multivariate analysis. These were donor sex, recipient sex, donor type, history of donor lymphocyte infusion, cGVHD severity, lung involvement, and skin involvement. The logistic regression demonstrated that matched related donors (odds ratio [OR], 0.149; 95% CI, 0.022-0.981; P = .048) and lung cGVHD (OR, 0.112; 95% CI, 0.020-0.639; P = .01) were associated with treatment failure (Figure 1C). Although lacking statistical significance, the haploidentical HSCT group had higher ORR than the matched-related HSCT group (25 of 32 [71.4%] vs 4 of 9 [44.4%]; P = .09). There was no significant difference between the haploidentical group and the matched group in cGVHD baseline, including cGVHD severity (severe cGVHD: 19 [59.3%] vs 8 [88.9%]; P = .13), number of previous second-line drugs (median [range], 3 [1-6] vs 3 [2-5]; P = .28), duration of cGVHD course (median [range], 9.6 [0.6-71.9] months vs 16.4 [1.0-44.0] months; P = .90), or involved organs (skin: 24 [75.0%] vs 4 [44.4%]; P = .11; mouth: 22 [68.8%] vs 7 [77.8%]; P = .70; lung: 14 [43.8%] vs 4 [44.4%]; P > .99; liver: 11 [34.3%] vs 4 [44.4%]; P = .70; eyes: 9 [28.1%] vs 5 [55.6%]; P = .23; joint and fascia: 6 [18.8%] vs 3 [33.3%]; P = .38).
Furthermore, 26 of 29 patients who responded and 4 of 5 patients with SD (30 of 34 [88.2%]) received concomitant prednisone at a median (range) dose of 15 (2.5-45) mg/d without any dose alteration within 2 weeks before the first administration of ruxolitinib. At the last dose of ruxolitinib, prednisone reduction occurred in 27 patients (90.0%) at a median (range) dose of 10 (0-20) mg/d, with a median (range) reduction of 50.0% (33.3%-100%). Of these 27 patients, dose was decreased for 19 (63.3%) and discontinued for 8 (26.7%). The median (range) dose of concomitant prednisone at 3 months, 6 months, and 12 months was 15 (0-35) mg/d, 10 (0-15) mg/d, and 7.5 (0-10) mg/d, respectively (Figure 1D).
In 23 patients (56.1%) receiving concomitant second-line immunosuppressive agents, including 2 patients with SD and 21 who responded, dosage reduction and discontinuation were observed in 15 patients (65.2%) and 6 patients (26.1%), respectively. Only 2 of 14 patients (14.3%) with PR continued tacrolimus with the same dose for maintenance.
The 6-month and 12-month OS rates for all treated patients were 87.8% (95% CI, 77.3%-98.3%) and 65.9% (95% CI, 50.7%-81.0%), respectively (Figure 2A). The median (range) follow-up was 14.9 (1.4-32.5) months. The univariate analysis showed that patients with a male donor (P = .006), complete remission before transplantation (P = .02), baseline moderate cGVHD (P = .02), and skin cGVHD (P = .001) might achieve prolonged survival (Figure 3). Grafts from a male donor were more likely to have skin cGVHD (18 of 20 [90.0%] vs 10 of 21 [47.6%]; P = .009), and most matched related donors were women (8 of 12 [66.7%] vs 1 of 20 [5.0%]; P = .02).
Figure 2. Overall Survival, Relapse Incidence, and Cumulative Flare Incidence During the Follow-up Period
cGVHD indicates chronic graft-vs-host disease; NRM indicates nonrelapsed mortality.
Figure 3. Survival Probabilities
cGVHD indicates chronic graft-vs-host disease; CR indicates complete remission; and HSCT indicates hematopoietic stem cell transplantation.
Safety Profile
All adverse effects occurring after ruxolitinib administration were documented (eTable in the Supplement). The prophylaxis against infection, including sulfamethoxazole for pneumocystis pneumonia and micafungin or posaconazole for invasive fungal disease, was provided for all patients. Eleven patients (26.8%; 6 [54.5%] with response and 5 [45.5%] with no response) experienced lung infection during ruxolitinib treatment, and 3 patients (27.3%) died due to the infection. Patients with lung involvement were more likely to develop lung infection (8 of 18 [44.4%] vs 3 of 23 [13.0%]; P = .04).
Cytomegalovirus (CMV) detection before and after the use of ruxolitinib was performed for 34 patients (82.9%), of whom 5 patients (14.7%) underwent CMV DNAemia. Similarly, Epstein-Barr virus (EBV) data for 7 patients were unavailable, and 19 of 36 patients (52.7%) experienced EBV DNAemia after ruxolitinib administration. Two patients (4.9%) and 1 patient (2.4%) had carbapenem-resistant Klebsiella pneumoniae sepsis and hepatitis B (HBV) reaction, respectively.
Cytopenias were reported during ruxolitinib treatment in 6 patients (14.6%), of which 3 (50.0%) were of grades 3 to 4, including 1 grade 4 thrombocytopenia and 2 grade 3 leukocytopenia/thrombocytopenia. In 1 patient (16.7%), thrombocytopenia was related to the use of sulfamethoxazole.
Eight patients (19.5%) had manifestations of necrosis of the femoral head. Overall, the recurrence of underlying malignant neoplasm was found in 6 patients (14.6%). The cumulative incidence is shown in Figure 2B. cGVHD flare was observed in 9 of 29 patients (31.0%) with response due to drug discontinuation, presenting mild cGVHD manifestations (Figure 2C). These patients had cGVHD flare in their previously involved organs, including mouth, skin, musculoskeleton, and kidney. Four patients (44.4%) with cGVHD flare restarted ruxolitinib and regained initial responses. Overall, 9 patients died (22.0%) due to relapse of the primary malignancy (5 [55.6%]), pneumonia (3 [33.3%]; Pneumocystis jiroveci pneumonia, invasive fungal disease, and fungal/bacteria mixed infection), and acute liver failure caused by HBV reaction (1 [11.1%]).
The 1-year and 2-year NRM rates were 8.6% and 12.5%, respectively. The 1-year and 2-year cumulative incidences of relapse were 10.6% and 17.1%, respectively (Figure 2B).
Discussion
The treatment strategies for patients with SR-cGVHD have changed. Multiple immunosuppressive agents provide clinicians with new approaches for treating patients with SR-cGVHD with few guidelines and a lack of consensus. Previous studies showed that the ORR of ruxolitinib in refractory cGVHD treatment was approximately 43.5% to 100%, and the CRR was from 3.5% to 13.0%, with a median time to best response ranging from 2 to 4 weeks.8,12,13,14 In the present study, the ORR was 70.7% (95% CI, 56.2%-85.3%), and the CRR was 36.6% (95% CI, 21.2%-52.0%). The median time to reach the best response was 2.0 months.
Ruxolitinib showed potential to resolve cGVHD. This study found that compared with patients with moderate cGVHD and less organ involvement, patients with severe and multiple involved organs had similar treatment outcome in terms of not only ORR but also the time to achieve response. Importantly, the treatment response showed no significant difference in patients with different previous lines of second-line agents and the time from cGVHD diagnosis to receiving ruxolitinib. The aforementioned scenario might suggest the use of ruxolitinib in patients with cGVHD regardless of cGVHD severity, the numbers of involved organs, the duration of cGVHD course, or the intensity of previous pharmacological therapies.
A primary aim of this study was to examine the factors associated with treatment response for ruxolitinib. The statistical results showed an association between lung cGVHD and treatment response, which was also reported in a previous study.13 The multivariate analysis indicated that among patients with cGVHD, lung involvement was associated with a higher risk of treatment failure.
The underlying mechanism of this association has not yet been elucidated. However, ensuing pulmonary fibrosis, symbolized with myofibroblast hyperplasia, is promoted by macrophages, B-cells, and complicated networks of other cells.15 A 3-phase model was developed for cGVHD in which the third phase is hypothesized to be due to the excessive accumulation of extracellular matrix, causing abnormal fibrosis.16
For example, interleukin 21 (IL-21) promotes the differentiation of B-cells into plasma cells via the JAK/signal transducer and activator of transcription 3 (STAT3) pathway, leading to antibody secretion and deposition.17 As an inhibitor of JAK-STAT signaling, ruxolitinib interferes with the activation and differentiation of T-cells and suppresses the activity of macrophages.18 However, the efficacy of ruxolitinib is not evident when it comes to the irreversible third phase, which is characterized by aberrant depositions and fibrosis. This explains the less effective results of ruxolitinib in lung cGVHD. In addition to treatment response, patients with lung cGVHD were more likely to develop pulmonary infection than patients with other types of cGVHD (8 of 18 [44.4%] vs 3 of 23 [13.0%]; P = .04). As such, patients without lung involvement were more likely to benefit from ruxolitinib. However, even the lungs could achieve a promising ORR of 50.0% in terms of difficulties in treating lung cGVHD. The ORR of other organs was similar, indicating that the pharmacokinetics of ruxolitinib could enable the distribution of the drug in target sites.
In this cohort, there was no significant difference between the haploidentical group and the matched group in cGVHD baseline, including cGVHD severity, number of previous second-line drugs, duration of cGVHD course, and involved organs. However, it is interesting to note that patients receiving haploidentical HSCT were observed to have higher ORR than those with matched related donors. Although JAK regulates the function of panoramic immune cells such as T-cells, B-cells, macrophages, and dendritic cells,7,19,20,21correlating with the etiology of cGVHD, the different treatment responses might underlie the heterogeneous pathogenesis of cGVHD between patients receiving stem cells from haploidentical and matched related donors. Currently, cGVHD is considered an entity, tantamount to an autoimmune disorder, with few comparisons in recipients receiving haploidentical and matched grafts. Thus, the potential disparities in the pathogenesis of cGVHD remain to be explored.
The cohort showed that male donors, CR before transplantation, skin cGVHD, and moderate cGVHD were associated with prolonged survival. This study found that patients receiving peripheral blood stem cells (PBSC) from male donors had more skin cGVHD events.
The estimated OS was compared between patients with and without a response. That the estimated OS plots were similar might ignore the fact that patients who responded had a higher quality of life, without or with fewer cGVHD events. A recent study demonstrated that the development of cGVHD was not associated with OS.22 In other words, survival time was comparatively fixed despite the resolution of cGVHD with the treatment of ruxolitinib. In this study, 23 patients had infections, including 11 with lung infection, 5 with CMV DNAemia, 19 with EBV DNAemia, 2 with sepsis, and 1 with HBV reaction. The latest REACH-1 study9 on aGVHD showed that infection events during ruxolitinib were approximately 80.3%, of which CMV events were the most common (19.7%). Zeiser et al8 found that the incidence of CMV events was higher in SR-aGVHD than in SR-cGVHD (33.3% vs 14.6%). Collectively, infection in patients with SR-cGVHD was tolerated, but 4 of 9 patients died of infection-related complications, highlighting the importance of antibacterial, antifungal, and antiviral prophylaxis.
Regarding cytopenia, the most common adverse effects related to ruxolitinib in the REACH-1 study were anemia (35.2%), thrombocytopenia (32.4%), and neutropenia (26.8%). The study by Zeiser et al8 showed that 5 patients with SR-aGVHD were more likely to develop global cytopenias and severe cytopenias compared with patients with cGVHD during the ruxolitinib course. The overall frequency of cytopenias in this study was only 14.6%, and grade 3 to 4 cytopenia occurred in 3 cases (7.3%), which was lower than the values reported in the study by Zeiser et al8 on the use of ruxolitinib in cGVHD and aGVHD.
Limitations
This study has limitations. First, this single-center study lacked sufficient participants and death events to perform a multivariate analysis. For example, we found no statistical significance of OS between patients who did and did not respond. The limited data size dramatically interfered with the P value, which might lead to nonsignificant results, and patients from a single center might contribute to survival bias. It is important to emphasize that because of the study’s observational and retrospective nature, the results should be interpreted with caution. Second, some results failed to provide key insights. While we found patients with haploidentical donors might receive more benefit from ruxolitinib compared with matched related donors, the underlying mechanism for this phenomenon remains unclear. Third, although we highlight that ruxolitinib as a single agent could lower expenditure, we could not measure the actual costs of ruxolitinib regarding its dosage and course of treatment.
Conclusions
This case series found that ruxolitinib in patients with SR-cGVHD had an ORR of 70.7% and CRR of 36.6%. Nearly all patients reduced the dose or discontinued the use of concomitant corticosteroids and other immunosuppressive drugs, minimizing their side effects and cost burden. Despite the limited sample size and retrospective nature, the results of this study indicated that patients with no lung involvement and haploidentical relatives as donors were more likely to benefit from ruxolitinib. Regarding the safety profile, the present study showed that infection events were the most severe adverse effect related to ruxolitinib, highlighting the significance of infection prophylaxis.
Supplement. eTable. Safety Profile of Ruxolitinib
Click here for additional data file. | RUXOLITINIB | DrugsGivenReaction | CC BY | 33502484 | 19,019,953 | 2021-01-04 |
What was the administration route of drug 'RUXOLITINIB'? | Evaluation of Ruxolitinib for Steroid-Refractory Chronic Graft-vs-Host Disease After Allogeneic Hematopoietic Stem Cell Transplantation.
Ruxolitinib, a selective inhibitor of the Janus kinases 1/2 signaling pathway, has shown a significant response in steroid-refractory chronic graft-vs-host disease (SR-cGVHD), a major cause of morbidity and mortality in individuals who have undergone allogeneic hematopoietic stem cell transplantation (HSCT).
To investigate the clinical response to ruxolitinib in patients with SR-cGVHD after allogeneic HSCT and to evaluate its safety profile during the treatment course.
This single-center case series included 41 consecutive patients who were treated with ruxolitinib for SR-cGVHD after allogeneic HSCT between August 2017 and December 2019. Data were collected from each patient's medical record at the First Affiliated Hospital of Zhejiang University School of Medicine. Data analysis was conducted from March to May 2020.
Ruxolitinib.
Treatment responses, factors associated with response, and adverse effects during ruxolitinib administration.
Overall, 41 patients (median [range] age, 31 [17-56] years; 14 [34.1%] women) were treated with ruxolitinib and included in this study. A total of 15 patients (36.6%) had a complete remission, and 14 (34.1%) had a partial remission, with an overall response rate of 70.7% (29 patients; 95% CI, 56.2%-85.3%). Lung involvement (odds ratio, 0.112; 95% CI, 0.020-0.639; P = .01) and matched related donors (odds ratio, 0.149; 95% CI, 0.022-0.981; P = .048) were associated with less favorable treatment response. Major adverse events associated with ruxolitinib were cytopenias and infectious complications. The median (range) follow-up for this cohort was 14.9 (1.4-32.5) months. Prolonged survival was observed in patients with a male donor (P = .006), complete remission before transplantation (P = .02), baseline moderate cGVHD (P = .02), and skin cGVHD (P = .001).
In this small, single-site case series, ruxolitinib demonstrated a significant response in heavily pretreated patients with SR-cGVHD and a reasonably well-tolerated safety profile. The results add to the body of literature suggesting ruxolitinib as a promising treatment option in SR-cGVHD.
Introduction
Chronic graft-vs-host disease (cGVHD) is the leading cause of late morbidity and mortality as well as impaired quality of life after allogeneic hematopoietic stem cell transplantation (HSCT).1 Despite the use of standard prophylaxis, 35% to 70% of recipients develop cGVHD.2 Established first-line therapy for cGVHD still comprises corticosteroids and calcineurin inhibitors.3 Approximately half of patients with cGVHD are refractory to corticosteroid therapy. For various second-line therapies or interventions, the response rates range from 30% to 60%,4,5 and no consensus has been reached regarding the optimal salvage treatment for steroid-refractory (SR)–cGVHD. Therefore, it is essential to identify a promising therapeutic drug for the adequate therapy of SR-cGVHD.
There is preclinical evidence that the pharmacologic inhibition of Janus kinases 1/2 (JAK1/J2) prevents GVHD by blocking interferon-γ receptor and interleukin 6 receptor signaling. JAK1/2 inhibition does not impair donor T-cell alloreactivity. It preserves the beneficial graft vs leukemia effect in vivo, suggesting a potential role for the selective JAK1/2 inhibitor ruxolitinib in the prevention and treatment of GVHD.6,7
A multicenter retrospective study in centers throughout Europe and the United States first established the feasibility of ruxolitinib for SR–acute GVHD (aGVHD) treatment.8 Thereafter, the Ruxolitinib for the Treatment of Steroid-Refractory Acute GVHD (REACH-1) study9 investigated ruxolitinib in treating SR-aGVHD and showed that the overall response rate (ORR) on day 28 was 54.9%. This was the first time such a study was conducted prospectively, and it shed light on later randomized clinical trials.9 Subsequently, a prospective study showed that combining ruxolitinib with another agent could achieve higher ORRs.10
At present, there is no standard of care for treating SR-cGVHD because of a lack of available and substantial data from prospective studies. The efficacy of ruxolitinib vs current best available therapy in SR-cGVHD is being evaluated in an ongoing phase 3 trial (REACH-3; NCT03112603).
Based on the limited preclinical and clinical outcomes of ruxolitinib in GVHD published to date, the present study investigated the clinical response to ruxolitinib and its safety profile in patients with SR-cGVHD after allogeneic HSCT. The study aimed to provide informative data for SR-cGVHD management and to measure the benefits and risks for different patient groups.
Methods
This retrospective, single-center case series included 41 consecutive patients who were treated with ruxolitinib for SR-cGVHD after allogeneic HSCT between August 2017 and December 2019 at the First Affiliated Hospital of Zhejiang University School of Medicine. Informed consent was obtained from all recruited patients before ruxolitinib treatment and data collection. For safety and response evaluation, all data were collected from clinical history at the First Affiliated Hospital of Zhejiang University School of Medicine. The study was reviewed and approved by the ethics committee of the First Affiliated Hospital of Zhejiang University School of Medicine. This study followed the reporting guideline for case series.
All patients were aged 10 years or older and were successfully engrafted with full donor chimerism. Patients undergoing allogeneic HSCT, diagnosed with moderate or severe cGVHD, and refractory to steroid-based therapy were included. cGVHD was defined and graded following the National Institutes of Health (NIH) criteria or confirmed biopsy. SR was defined as cGVHD worsening on prednisone of at least 1 mg/kg/d for 1 to 2 weeks or sustained use of prednisone of a least 0.5 mg/kg/d (or 1 mg/kg every other day) for at least 4 weeks.11
Enrolled patients received ruxolitinib orally. Normally, a patient weighing 60 kg or less received a dose of 5 mg twice daily; patients weighing more than 60 kg received 10 mg twice a day. Patients with grade 3 cytopenia (according to National Cancer Institute–Common Terminology Criteria for Adverse Events [NCI-CTCAE] version 4.0) received 5 mg once a day. If patients presented worsening cGVHD according to NIH criteria within 4 weeks after administration, ruxolitinib would be withdrawn.
Response evaluation was conducted according to clinical status in the sixth month after the first ruxolitinib administration. The ORR included complete response (CR) and partial response (PR). CR was defined as the absence of all manifestations of cGVHD; PR was defined as an improvement in cGVHD compared with baseline clinical status and stage according to the NIH consensus and without any progression in any organs or sites. Other situations, including stable disease (SD), defined as no changes, and progressive disease (PD), defined as worsening in at least 1 site or organ, were categorized as treatment failure; discontinuation because of toxic effects from ruxolitinib was not included.
We collected and analyzed the following data: (1) adverse events, such as infections and cytopenia based on NCI-CTCAE version 4.0, were clinically relevant as grade 2 or higher; (2) time to response, defined as the initial use of ruxolitinib to initial response; (3) nonrelapsed mortality (NRM), which was defined as the initial treatment of ruxolitinib until death from any cause except underlying malignant neoplasm relapse or recurrence; (4) overall survival (OS), which was defined as the initial treatment of ruxolitinib until death from any cause; (5) cumulative incidence of cGVHD flare, which was defined as the initial use of ruxolitinib until cGVHD progression; and (6) the cumulative relapse of underlying malignant neoplasm, which was defined as the initial use of ruxolitinib until the first relapse. Patients who were lost to the last follow-up were censored.
Statistical Analysis
Data were analyzed using SPSS statistical software version 22.0.01 (IBM Corp). A 2-tailed P < .05 was considered statistically significant. Univariate comparisons of parameters were performed using the χ2 test, Fisher exact test, and t test, as appropriate. Variables with P < .20 in univariate analysis were entered into the multivariate model. OS was estimated and plotted using the Kaplan-Meier method. The log-rank test was applied to compare Kaplan-Meier curves. The proportional-hazards method was used to estimate the cumulative incidence of relapse and NRM. Relapse and NRM were competing risks for each other. R statistical software version 3.4.3 (R Project for Statistical Computing) was used for the competing risk analysis.
Results
Patients
Between August 2017 and December 2019, 41 patients with SR-cGVHD, with a median (range) age of 31 (17-56) years and 14 (34.1%) women, were treated with ruxolitinib and included in this study. The demographic and baseline characteristics of the 41 participants are summarized in Table 1. Acute lymphoid leukemia (18 [43.9%]) and acute myeloid leukemia (17 [41.5%]) were the 2 most common diagnoses. All peripheral blood stem cells were obtained from related donors, including 9 patients (22.0%) receiving human leukocyte antigen (HLA)–matched grafts and 32 patients (78.0%) receiving HLA-haploidentical grafts. Only 1 patient (2.4%) underwent reduced-intensity conditioning, and antithymocyte globulin was administrated to the 32 patients (78.0%) receiving HLA-haploidentical transplantation (Table 1).
Table 1. Patient, Donor, and Transplant Characteristics
Characteristic No. (%)
Patient age, median (range), y 31 (17-56)
Men 27 (65.9)
Male donor 20 (48.8)
Haploidentical donor 32 (78.0)
HLA-matched relative 9 (22.0)
Donor-recipient gender
FF 9 (22.0)
MM 19 (46.3)
FM 10 (24.4)
MF 3 (7.3)
Stem cell source
PBSC 41 (100)
Diagnosis
ALL 18 (43.9)
AML 17 (41.5)
Other 6 (14.6)
Disease status at transplant
CR 37 (90.2)
PR 2 (4.9)
Progressive 2 (4.8)
Conditioning regimen
MAC 40 (97.6)
RIC 1 (2.4)
Use of ATG
Yes 32 (78.0)
No 9 (22.0)
Prior acute graft-vs-host disease
No 8 (19.5)
Grade I to II 21 (51.2)
Grade III to IV 12 (29.3)
Abbreviations: ALL, acute lymphoid leukemia; AML, acute myeloid leukemia; ATG, antithymoglobuline; CR, complete remission; FF, female to female; FM, female to male; HLA, human leukocyte antigen; MAC, myeloablative conditioning; MF, male to female; MM, male to male; PBSC, peripheral blood stem cell; PR, partial remission; RIC, reduced intensity conditioning.
A total of 32 patients (78.0%) developed prior aGVHD, with grade I (11 [34.4%]), grade II (10 [24.4%]), grade III (8 [25.0%]), and grade IV (4 [12.5%]). The median (range) time from HSCT to cGVHD diagnosis was 9.0 (3.3-27.2) months. Two patients (4.9%) showing overlap syndrome were enrolled in the study. At the time of enrollment, 27 patients (65.9%) had severe cGVHD, and 14 patients (34.1%) had moderate cGVHD. Organ involvement included skin (28 [68.3%]), mouth (29 [70.7%]), lungs (18 [43.9%]), liver (15 [36.6%]), eyes (14 [34.1%]), musculoskeleton (9 [22.0%]), kidney (3 [7.3%]), genitalia (3 [7.3%]), gastrointestinal tract (2 [4.9%]), eosinophilia (2 [4.9%]), nails (2 [4.9%]), and others (3 [7.3%]) (Table 2). More than half of patients (24 [58.5%]) had more than 2 sites or organs involved. No patient received posttransplant cyclophosphamide as GVHD prophylaxis.
Table 2. Characteristics of cGVHD
Characteristic No. (%,)
Time from transplantation to cGVHD, median (range), mo 9.0 (3.3-27.2)
Overlap syndrome 2 (4.9)
Severe NIH score 27 (65.9)
Moderate NIH score 14 (34.1)
Organ affected
Skin 28 (68.3)
Mouth 29 (70.7)
Lungs 18 (43.9)
Liver 15 (36.6)
Eyes 14 (34.1)
Joint and fascia 9 (22.0)
Genitalia 3 (7.3)
Kidney 3 (7.3)
Gastrointestinal tract 2 (4.9)
Nails 2 (4.9)
Involved sites
1 6 (14.6)
2 11 (26.8)
3 13 (31.7)
4 5 (12.2)
>4 6 (14.6)
Previous second-line agents, median (range) 3 (1-6)
Previous agents
Tacrolimus 36 (87.8)
Mycophenolate mofetil 26 (65.0)
Imatinib 15 (36.6)
CsA 15 (36.6)
Methotrexate 12 (29.3)
Mesenchymal stem cells 9 (22.0)
Infliximab 7 (17.1)
Others 10 (24.3)
Time from cGVHD to initial ruxolitinib treatment, median (range), mo 11.0 (0.6-71.9)
Abbreviations: CsA, cyclosporine A; cGVHD, chronic graft-vs-host disease; NIH, National Institutes of Health.
The median (range) number of second-line immunosuppressive agents before ruxolitinib was 3 (1-6). Tacrolimus (36 [87.8%]) and mycophenolate mofetil (26 [65.0%]) were the most commonly used agents. Ruxolitinib was started at a median (range) of 11.0 (0.6-71.9) months after the diagnosis of cGVHD (Table 2).
Response, Outcomes, and Long-term Survival
After a median (range) duration of 7.5 (1.0-24.9) months of ruxolitinib treatment, the ORR at 6 months was 70.7% (29 of 41 patients), including 15 patients (36.6%) with CR and 14 patients (34.1%) with PR. Among 12 patients (29.3%) with treatment failure, 5 (41.7%) had SD and 7 (58.3%) had PD (Figure 1A). The median (range) time to response was 2 (0.5-6.0) months. Ruxolitinib treatment was continued for a median (range) of 8.6 (1.1-24.9) months in those who responded. Patients with moderate cGVHD and those with severe cGVHD had similar ORRs (12 of 14 [85.7%] vs 17 of 27 [63.0%]; P = .17) and time to response (median [range], 2.3 [0.5-6.0] months vs 2.0 [1.0-6.0] months; P = .66). The number of involved organs was not associated with ORR or the time to response. There was no significant difference between patients who responded vs those who did not regarding previous lines of second-line agents (median [range], 4 [1-5] vs 3 [1-6]; P = .60) or time from cGVHD diagnosis to receiving ruxolitinib (median [range], 9.0 [0.6-71.9] months vs 14.1 [1.7-67.4] months; P = .89). Seven patients (17.1%) had ruxolitinib duration of less than 6 months because of death events (4 patients [57.1%]) and self-withdrawal due to favorable responses (3 patients [42.9%]). Compared with patients without lung cGVHD, the global ORR of those with lung involvement was relatively low (20 of 23 [87.0%] vs 9 of 18 [50.0%], P = .01). The ORR was 22 of 28 (78.6%) in the skin, 22 of 29 (75.9%) in the mouth, 8 of 14 (57.1%) in eyes, 2 of 2 (100%) in the gastrointestinal tract, 12 of 15 (80.0%) in the liver, 9 of 18 (50.0%) in the lungs, 5 of 9 (55.6%) in the musculoskeleton, and 1 of 3 (33.3%) in genitalia (Figure 1B). In this cohort, 18 patients (43.9%) discontinued ruxolitinib administration because of treatment failure (11 [61.1%]), relapse of underlying malignant neoplasm (6 [33.3%]), and lung infection (1 [5.6%]).
Figure 1. Treatment Response and Prednisone Dose Among 41 Patients with Steroid-Refractory Chronic Graft-vs-Host Disease (cGVHD)
Median (range) treatment duration was 8.6 (1.1-24.9) months in responders. CR indicates complete remission; GI, gastrointestinal tract; PD, progressive disease; PR, partial remission; and SD, stable disease.
Variables with P < .20 in the univariate analysis were included in the later multivariate analysis. These were donor sex, recipient sex, donor type, history of donor lymphocyte infusion, cGVHD severity, lung involvement, and skin involvement. The logistic regression demonstrated that matched related donors (odds ratio [OR], 0.149; 95% CI, 0.022-0.981; P = .048) and lung cGVHD (OR, 0.112; 95% CI, 0.020-0.639; P = .01) were associated with treatment failure (Figure 1C). Although lacking statistical significance, the haploidentical HSCT group had higher ORR than the matched-related HSCT group (25 of 32 [71.4%] vs 4 of 9 [44.4%]; P = .09). There was no significant difference between the haploidentical group and the matched group in cGVHD baseline, including cGVHD severity (severe cGVHD: 19 [59.3%] vs 8 [88.9%]; P = .13), number of previous second-line drugs (median [range], 3 [1-6] vs 3 [2-5]; P = .28), duration of cGVHD course (median [range], 9.6 [0.6-71.9] months vs 16.4 [1.0-44.0] months; P = .90), or involved organs (skin: 24 [75.0%] vs 4 [44.4%]; P = .11; mouth: 22 [68.8%] vs 7 [77.8%]; P = .70; lung: 14 [43.8%] vs 4 [44.4%]; P > .99; liver: 11 [34.3%] vs 4 [44.4%]; P = .70; eyes: 9 [28.1%] vs 5 [55.6%]; P = .23; joint and fascia: 6 [18.8%] vs 3 [33.3%]; P = .38).
Furthermore, 26 of 29 patients who responded and 4 of 5 patients with SD (30 of 34 [88.2%]) received concomitant prednisone at a median (range) dose of 15 (2.5-45) mg/d without any dose alteration within 2 weeks before the first administration of ruxolitinib. At the last dose of ruxolitinib, prednisone reduction occurred in 27 patients (90.0%) at a median (range) dose of 10 (0-20) mg/d, with a median (range) reduction of 50.0% (33.3%-100%). Of these 27 patients, dose was decreased for 19 (63.3%) and discontinued for 8 (26.7%). The median (range) dose of concomitant prednisone at 3 months, 6 months, and 12 months was 15 (0-35) mg/d, 10 (0-15) mg/d, and 7.5 (0-10) mg/d, respectively (Figure 1D).
In 23 patients (56.1%) receiving concomitant second-line immunosuppressive agents, including 2 patients with SD and 21 who responded, dosage reduction and discontinuation were observed in 15 patients (65.2%) and 6 patients (26.1%), respectively. Only 2 of 14 patients (14.3%) with PR continued tacrolimus with the same dose for maintenance.
The 6-month and 12-month OS rates for all treated patients were 87.8% (95% CI, 77.3%-98.3%) and 65.9% (95% CI, 50.7%-81.0%), respectively (Figure 2A). The median (range) follow-up was 14.9 (1.4-32.5) months. The univariate analysis showed that patients with a male donor (P = .006), complete remission before transplantation (P = .02), baseline moderate cGVHD (P = .02), and skin cGVHD (P = .001) might achieve prolonged survival (Figure 3). Grafts from a male donor were more likely to have skin cGVHD (18 of 20 [90.0%] vs 10 of 21 [47.6%]; P = .009), and most matched related donors were women (8 of 12 [66.7%] vs 1 of 20 [5.0%]; P = .02).
Figure 2. Overall Survival, Relapse Incidence, and Cumulative Flare Incidence During the Follow-up Period
cGVHD indicates chronic graft-vs-host disease; NRM indicates nonrelapsed mortality.
Figure 3. Survival Probabilities
cGVHD indicates chronic graft-vs-host disease; CR indicates complete remission; and HSCT indicates hematopoietic stem cell transplantation.
Safety Profile
All adverse effects occurring after ruxolitinib administration were documented (eTable in the Supplement). The prophylaxis against infection, including sulfamethoxazole for pneumocystis pneumonia and micafungin or posaconazole for invasive fungal disease, was provided for all patients. Eleven patients (26.8%; 6 [54.5%] with response and 5 [45.5%] with no response) experienced lung infection during ruxolitinib treatment, and 3 patients (27.3%) died due to the infection. Patients with lung involvement were more likely to develop lung infection (8 of 18 [44.4%] vs 3 of 23 [13.0%]; P = .04).
Cytomegalovirus (CMV) detection before and after the use of ruxolitinib was performed for 34 patients (82.9%), of whom 5 patients (14.7%) underwent CMV DNAemia. Similarly, Epstein-Barr virus (EBV) data for 7 patients were unavailable, and 19 of 36 patients (52.7%) experienced EBV DNAemia after ruxolitinib administration. Two patients (4.9%) and 1 patient (2.4%) had carbapenem-resistant Klebsiella pneumoniae sepsis and hepatitis B (HBV) reaction, respectively.
Cytopenias were reported during ruxolitinib treatment in 6 patients (14.6%), of which 3 (50.0%) were of grades 3 to 4, including 1 grade 4 thrombocytopenia and 2 grade 3 leukocytopenia/thrombocytopenia. In 1 patient (16.7%), thrombocytopenia was related to the use of sulfamethoxazole.
Eight patients (19.5%) had manifestations of necrosis of the femoral head. Overall, the recurrence of underlying malignant neoplasm was found in 6 patients (14.6%). The cumulative incidence is shown in Figure 2B. cGVHD flare was observed in 9 of 29 patients (31.0%) with response due to drug discontinuation, presenting mild cGVHD manifestations (Figure 2C). These patients had cGVHD flare in their previously involved organs, including mouth, skin, musculoskeleton, and kidney. Four patients (44.4%) with cGVHD flare restarted ruxolitinib and regained initial responses. Overall, 9 patients died (22.0%) due to relapse of the primary malignancy (5 [55.6%]), pneumonia (3 [33.3%]; Pneumocystis jiroveci pneumonia, invasive fungal disease, and fungal/bacteria mixed infection), and acute liver failure caused by HBV reaction (1 [11.1%]).
The 1-year and 2-year NRM rates were 8.6% and 12.5%, respectively. The 1-year and 2-year cumulative incidences of relapse were 10.6% and 17.1%, respectively (Figure 2B).
Discussion
The treatment strategies for patients with SR-cGVHD have changed. Multiple immunosuppressive agents provide clinicians with new approaches for treating patients with SR-cGVHD with few guidelines and a lack of consensus. Previous studies showed that the ORR of ruxolitinib in refractory cGVHD treatment was approximately 43.5% to 100%, and the CRR was from 3.5% to 13.0%, with a median time to best response ranging from 2 to 4 weeks.8,12,13,14 In the present study, the ORR was 70.7% (95% CI, 56.2%-85.3%), and the CRR was 36.6% (95% CI, 21.2%-52.0%). The median time to reach the best response was 2.0 months.
Ruxolitinib showed potential to resolve cGVHD. This study found that compared with patients with moderate cGVHD and less organ involvement, patients with severe and multiple involved organs had similar treatment outcome in terms of not only ORR but also the time to achieve response. Importantly, the treatment response showed no significant difference in patients with different previous lines of second-line agents and the time from cGVHD diagnosis to receiving ruxolitinib. The aforementioned scenario might suggest the use of ruxolitinib in patients with cGVHD regardless of cGVHD severity, the numbers of involved organs, the duration of cGVHD course, or the intensity of previous pharmacological therapies.
A primary aim of this study was to examine the factors associated with treatment response for ruxolitinib. The statistical results showed an association between lung cGVHD and treatment response, which was also reported in a previous study.13 The multivariate analysis indicated that among patients with cGVHD, lung involvement was associated with a higher risk of treatment failure.
The underlying mechanism of this association has not yet been elucidated. However, ensuing pulmonary fibrosis, symbolized with myofibroblast hyperplasia, is promoted by macrophages, B-cells, and complicated networks of other cells.15 A 3-phase model was developed for cGVHD in which the third phase is hypothesized to be due to the excessive accumulation of extracellular matrix, causing abnormal fibrosis.16
For example, interleukin 21 (IL-21) promotes the differentiation of B-cells into plasma cells via the JAK/signal transducer and activator of transcription 3 (STAT3) pathway, leading to antibody secretion and deposition.17 As an inhibitor of JAK-STAT signaling, ruxolitinib interferes with the activation and differentiation of T-cells and suppresses the activity of macrophages.18 However, the efficacy of ruxolitinib is not evident when it comes to the irreversible third phase, which is characterized by aberrant depositions and fibrosis. This explains the less effective results of ruxolitinib in lung cGVHD. In addition to treatment response, patients with lung cGVHD were more likely to develop pulmonary infection than patients with other types of cGVHD (8 of 18 [44.4%] vs 3 of 23 [13.0%]; P = .04). As such, patients without lung involvement were more likely to benefit from ruxolitinib. However, even the lungs could achieve a promising ORR of 50.0% in terms of difficulties in treating lung cGVHD. The ORR of other organs was similar, indicating that the pharmacokinetics of ruxolitinib could enable the distribution of the drug in target sites.
In this cohort, there was no significant difference between the haploidentical group and the matched group in cGVHD baseline, including cGVHD severity, number of previous second-line drugs, duration of cGVHD course, and involved organs. However, it is interesting to note that patients receiving haploidentical HSCT were observed to have higher ORR than those with matched related donors. Although JAK regulates the function of panoramic immune cells such as T-cells, B-cells, macrophages, and dendritic cells,7,19,20,21correlating with the etiology of cGVHD, the different treatment responses might underlie the heterogeneous pathogenesis of cGVHD between patients receiving stem cells from haploidentical and matched related donors. Currently, cGVHD is considered an entity, tantamount to an autoimmune disorder, with few comparisons in recipients receiving haploidentical and matched grafts. Thus, the potential disparities in the pathogenesis of cGVHD remain to be explored.
The cohort showed that male donors, CR before transplantation, skin cGVHD, and moderate cGVHD were associated with prolonged survival. This study found that patients receiving peripheral blood stem cells (PBSC) from male donors had more skin cGVHD events.
The estimated OS was compared between patients with and without a response. That the estimated OS plots were similar might ignore the fact that patients who responded had a higher quality of life, without or with fewer cGVHD events. A recent study demonstrated that the development of cGVHD was not associated with OS.22 In other words, survival time was comparatively fixed despite the resolution of cGVHD with the treatment of ruxolitinib. In this study, 23 patients had infections, including 11 with lung infection, 5 with CMV DNAemia, 19 with EBV DNAemia, 2 with sepsis, and 1 with HBV reaction. The latest REACH-1 study9 on aGVHD showed that infection events during ruxolitinib were approximately 80.3%, of which CMV events were the most common (19.7%). Zeiser et al8 found that the incidence of CMV events was higher in SR-aGVHD than in SR-cGVHD (33.3% vs 14.6%). Collectively, infection in patients with SR-cGVHD was tolerated, but 4 of 9 patients died of infection-related complications, highlighting the importance of antibacterial, antifungal, and antiviral prophylaxis.
Regarding cytopenia, the most common adverse effects related to ruxolitinib in the REACH-1 study were anemia (35.2%), thrombocytopenia (32.4%), and neutropenia (26.8%). The study by Zeiser et al8 showed that 5 patients with SR-aGVHD were more likely to develop global cytopenias and severe cytopenias compared with patients with cGVHD during the ruxolitinib course. The overall frequency of cytopenias in this study was only 14.6%, and grade 3 to 4 cytopenia occurred in 3 cases (7.3%), which was lower than the values reported in the study by Zeiser et al8 on the use of ruxolitinib in cGVHD and aGVHD.
Limitations
This study has limitations. First, this single-center study lacked sufficient participants and death events to perform a multivariate analysis. For example, we found no statistical significance of OS between patients who did and did not respond. The limited data size dramatically interfered with the P value, which might lead to nonsignificant results, and patients from a single center might contribute to survival bias. It is important to emphasize that because of the study’s observational and retrospective nature, the results should be interpreted with caution. Second, some results failed to provide key insights. While we found patients with haploidentical donors might receive more benefit from ruxolitinib compared with matched related donors, the underlying mechanism for this phenomenon remains unclear. Third, although we highlight that ruxolitinib as a single agent could lower expenditure, we could not measure the actual costs of ruxolitinib regarding its dosage and course of treatment.
Conclusions
This case series found that ruxolitinib in patients with SR-cGVHD had an ORR of 70.7% and CRR of 36.6%. Nearly all patients reduced the dose or discontinued the use of concomitant corticosteroids and other immunosuppressive drugs, minimizing their side effects and cost burden. Despite the limited sample size and retrospective nature, the results of this study indicated that patients with no lung involvement and haploidentical relatives as donors were more likely to benefit from ruxolitinib. Regarding the safety profile, the present study showed that infection events were the most severe adverse effect related to ruxolitinib, highlighting the significance of infection prophylaxis.
Supplement. eTable. Safety Profile of Ruxolitinib
Click here for additional data file. | Oral | DrugAdministrationRoute | CC BY | 33502484 | 19,019,953 | 2021-01-04 |
Give an alphabetized list of all active substances of drugs taken by the patient who experienced 'Septic shock'. | A case of round pneumonia due to Enterobacter hormaechei: the need for a standardized diagnosis and treatment approach in adults.
Round pneumonia is an unusual radiological manifestation of a bacterial lung infection. We present the case of an elderly male patient who arrived at the emergency room with a productive cough and exertional dyspnea. His chest x-ray and CT showed a round opacity and air bronchograms in the right upper lobe. Taken together, the patient's symptoms and images strongly suggest a pulmonary infection. Empirical antibiotic therapy with ceftriaxone and clarithromycin was started. The sputum culture was positive for Enterobacter hormaechei and the bacterium was sensitive to levofloxacin; therefore, the antibiotic therapy was changed. Despite the treatment, the patient progressed to respiratory failure and septic shock, dying six days after admission. Although round pneumonia is uncommon, it is a potentially curable disease and clinicians should always consider it in their differential diagnosis.
INTRODUCTION
Round pneumonia is an unusual radiological manifestation that varies from a small circular mass to a large undefined round opacity1. Only one percent of round pneumonia cases occur in adults2. Clinical presentations range from asymptomatic to a history of fever, productive cough and chills3,4. We report the case of an elderly adult admitted to the emergency room with exertional dyspnea.
CASE REPORT
A 64-year-old male with a history of alcohol consumption and liver cirrhosis arrived at the emergency department with a two-day history of productive cough and exertional dyspnea. The initial examination revealed a temperature of 36 °C, blood pressure 100/60 mmHg, heart rate 78 bpm and respiratory rate 19 bpm with an oxygen saturation of 96% in ambient air. On admission, a round opacity was observed in the right upper lobe on his chest X-ray (Figure 1). Laboratory tests were within normal ranges. Antibiotic therapy for community-acquired pneumonia was started with intravenous ceftriaxone and oral clarithromycin. The sputum culture was positive for E. hormaechei and the bacterium was sensitive to levofloxacin. Therapy was modified accordingly. Matrix-Assisted Laser Desorption Ionization–Time of Flight Mass Spectrometry analysis was used for the initial bacterial identification, while antimicrobial susceptibility testing was performed with the MicroScan WalkAway 96 plus system (Beckman Coulter Life Sciences, Indianapolis, IN, USA), proven by the Minimum Inhibitory Concentration (MIC), and interpretation/classification following the Clinical and Laboratory Standards Institute guidelines5 (Table 1).
Figure 1 (A) Well circumscribed opacity in the right upper lobe of the chest x-ray of our 64-year-old patient; (B) A focal round opacity with an air bronchogram at the upper lobe of the right lung on a chest CT scan was seen in our patient.
Table 1 Minimum inhibitory concentration (MIC) values of antimicrobial agents against E. hormaechei.
Antibiotic MIC Interpretation
Amikacin ≤ 16 Susceptible
Amoxicillin-clavulanate > 16/8 Resistant
ampicillin-sulbactam > 16/8 Resistant
Ampicillin > 16 Resistant
Cefazolin > 16 Resistant
Cefepime ≤ 4 Susceptible
Cefotaxime > 32 Resistant
Ceftazidime > 16 Resistant
Ceftriaxone > 32 Resistant
Cefuroxime > 16 Resistant
Ciprofloxacin ≤ 1 Susceptible
Ertapenem 1 Intermediate
Gentamicin ≤ 2 Susceptible
Imipenem/cilastatin ≤ 1 Susceptible
Levofloxacin ≤ 2 Susceptible
Meropenem ≤ 1 Susceptible
Piperacillin-tazobactam 32 Intermediate
Tetracycline ≤ 4 Susceptible
Tigecycline ≤ 2 Susceptible
Tobramycin ≤ 4 Susceptible
Trimethoprim-sulfamethoxazole ≤ 2/38 Susceptible
Forty-eight hours after presentation to the emergency room, the patient developed a systemic respiratory distress syndrome, was intubated and transferred to the intensive care unit. Mechanical ventilation with a lung-protective strategy was provided. During his ICU stay the patient developed hemodynamic instability. Additional blood cultures were drawn and there was a subsequent antibiotic therapy escalation with imipenem/cilastatin; however, the patient did not respond and died of septic shock.
DISCUSSION
Round pneumonia is a radiological and clinical entity described as the result of an infection that spreads centrifugally through the accessory connections between bronchioles and alveoli (canals of Lambert), between alveoli (pores of Kohn), or by destroying the acini walls. Another theory sustains that underdeveloped pores of Kohn and the absence of canals of Lambert limit the spread of the organism, resulting in a focal, round lesion in the lung1.
Physicians are obliged to differentiate between an infectious and a malignant etiology, which appears to be challenging in this presentation. An air bronchogram is found in 5- 50% of cases on CT scans in adults1; however, up to 65% of malignant nodules present with this same radiological pattern. Therefore, an air bronchogram does not seem to help distinguishing between round pneumonia and malignancy.
Wagner et al.1 reported that round pneumonia is more frequent in the lower lobe; accordingly, upper lobe lesions are especially suspicious of malignancy. It is important to note that, in contrast to what is reported in the existing literature, the predominance of these lesions in the upper lobe of the lung was found in the most contemporary review: nine (53.0%) cases in the upper lobes, six (35.3%) cases in the lower lobe and 2 (12.7%) cases in the middle lobe (Table 1). The predominance of the upper lobe has also been confirmed in this case. The mean age of patients of the cited studies is 45.2 years; this finding is similar to a previously reported case with a mean age of 40.93. This may help raising the suspicion that this is an infectious rather than a neoplastic process.
Infectious round infiltrates resolve over time, and the recommended assessment is through a repeated chest X-ray approximately eight weeks after treatment initiation6,7. However, studies in pediatric populations suggest that a follow-up chest X-ray is of limited value for those with a good response to medication8. Current practice guidelines of community-acquired pneumonia do not indicate the follow-up of patients with thoracic images if clinical improvement is evident, but recommendations for adults diagnosed with round pneumonia are not explicitly stated9.
Similar to patients with lobar pneumonia, the ideal antibiotic treatment should be directed against the most common bacterial pathogens (Streptococcus pneumoniae, Klebsiella pneumoniae, and Haemophilus influenza)4,10. However, some authors suggest that Q fever is currently the leading cause of round pneumonia in adults.
First-line therapy consists of doxycycline, but macrolides (erythromycin and clarithromycin) and quinolones (levofloxacin) are also curative and prevent the progression to chronic Q fever11. The duration of treatment for community-acquired pneumonia in current guidelines suggests a short 5-day course of antibiotics. Only patients without clinical improvement receive extended antibiotic therapy and further diagnostic approach9. Current antibiotic regimens for round pneumonia are typically long and highly heterogeneous, with duration ranging from 1 to 6 weeks (Table 2)3,4,12-24. In this regard, evidence-based recommendations on the duration of antibiotics in round pneumonia are needed. The pathogen identified in our case was E. hormaechei, which is a bacteria of the family Enterobacteriaceae that grows in most routine microbiological media and is identified by conventional tests25. Susceptibility testing can be performed using agar dilution, broth microdilution or disk diffusion. E. hormaechei is commonly susceptible to aminoglycosides, third-generation cephalosporins, carbapenems, and TMP/SMX, but resistant to aminopenicillins and penicillin G. According to a previous study, it is also susceptible to fluoroquinolones, but this finding contrasts with other reports26. Our patient had a poor clinical response to intravenous levofloxacin; for this reason, we switched to imipenem/cilastatin, but with no response. Risk factors for infection with Enterobacter spp. include immunosuppression, recent surgery, length of ICU stay, presence of an indwelling vascular or urinary catheter, and previous use of antibiotics26,27.
Table 2 Main clinical, radiological and treatment characteristics of case reports on round pneumonia over the last 20 years.
Articles Sex Age Risk factors Main complaint Chest image Subsequent image Antibiotic Treatment duration Bacterial pathogen Outcome
Gupta et al. 12
Female 29 None Fever and cough Chest X-ray and chest CT scan, right upper lobe ChestX-ray, 2 weeks Not specified 2 weeks Not identified Resolution
Yoshimura et al.
13
Male 43 History of recent travel Fever, fatigue, and headache Chest X-ray and chest CT scan, right lower lobe Not specified, 2 months minocycline 3 days
Rickettsia typhi
Resolution
Mahmood et al.14
Female 74 Current smoker and older age Dry cough and shortness of breathe Chest X-ray and chest CT scan, right lower lobe chest CT scan, 8 weeks Not specified Not specified
Streptococcus pneumoniae
Resolution
Harvey et al.
15
Female 70 Older age Fever, shortness of breathe, and productive cough Chest X-ray and chest CT scan, right upper lobe chest CT, not specified co-amoxiclav and clarithromycin Not specified Not identified Resolution
Cunha et al.16
Male 50 schizophrenia Cough, fever, myalgias, and shortness of breathe Chest X-ray, right upper lobe ChestX-ray, 8 weeks doxycycline 6 weeks Not identified Resolution
Köhne et al.
17
Male 55 Current smoker, seizures. Parkinson´s disease Fever and cough Chest X-ray and chest CT scan left upper lobe chest CT scan, 2 weeks ceftriaxone 2 weeks Not identified Resolution
Velasco-Tirado et al.
18
Male 58 zoonosis (cats) Fever, chills, headache, and abdominal pain Chest X-ray and chest CT scan, right upper lobe chest CT scan, 2 weeks doxycycline Not specified
Rickettsia typhi
Resolution
Velasco-Tirado et al.
18
Male 20 zoonosis (dog) Fever, dry cough, arthralgias, myalgias, headache, sweating and vomiting ChestX-ray , Right middle lobe ChestX-ray, 2 weeks doxycycline Not specified
Rickettsia typhi
Resolution
Kara et al.19
Female 26 None Fever and myalgia Chest X-ray and chest CT scan, Right middle lobe Not specified clarithromycin 10 days None. Resolution
Rodríguez20
Female 44 Current smoker, diabetes Fever, dyspnea, chest pain Chest X-ray and chest CT scan left lower lobe ChestX-ray, 1 week co-amoxiclav 7 days None Resolution
Jiménez-Castillo et al.21
Male 40 HIV infection Fever, headache, and fatigue Chest x-ray and chest CT scan left lower lobe Chest X-ray and chest CT scan, 4 days Co-trimoxazole 21 days
Pneumocystis jirovecii
Resolution
Violante-Cumpa et al.
22
Male 44 Diabetes and chronic kidney disease Dyspnea, orthopnea, and asthenia Chest X-ray h and chest CT scan left upper lobe Not specified Ceftriaxone and clarithromycin 7 days None Resolution
Zhang et al.23
Male 43 None Fever, chills, and cough Chest X-ray and chest CT scan left upper lobe chest CT scan, 2 weeks and 6 weeks Ceftriaxone and azithromycin 2 weeks none Resolution
Zylberman et al.
24
Female 24 None Fever and dry cough Chest X-ray and chest CT scan, right upper lobe. ChestX-ray, 1 week erythromycin 1 week
Chlamydia psittaci
Resolution
Zylberman et al.
24
Female 34 None Fever, dyspnea, and hemoptysis Chest X-ray and chest CT scan, right upper lobe Chest X-ray and chest CT scan, 1 week Ampicillin–sulbactam plus clarithromycin 11 days none Resolution
Durning et al.4
Female 58 None Fever, cough, and dyspnea. Chest X-ray left lower lobe ChestX-ray, 2 weeks Levofloxacin 14 days none Resolution
Camargo et al.3
Female 57 Current smoker Asymptomatic Chest X-ray right lower lobe ChestX-ray, 3 weeks none none Not applicable Resolution
Round pneumonia is an easily treatable infection as was corroborated by most of the cases reviewed here, but patients with abnormal immunity could progress rapidly to a life-threatening presentation10. We treated our patient according to bacterial susceptibility; despite this, his clinical evolution was unsatisfactory, potentially due to his history of liver cirrhosis, which has been associated with several abnormalities in innate and adaptive components of the immune system, leading to a state of acquired immunodeficiency and failure to resolve with standard therapy28. Laboratory tests for evaluation of cellular or antibody deficiencies were not available in our hospital at that moment.
The need for a standardized diagnosis and treatment approach in adults with round pneumonia is present. To the best of our knowledge, this is the first report on a case of round pneumonia due to E. hormaechei. There are several causes of oval lesions on chest images, however, clinicians should always have in mind this atypical presentation of a common disease.
ACKNOWLEDGMENTS
We thank Sergio Lozano-Rodriguez, MD, for his critical review of the manuscript. | CILASTATIN SODIUM\IMIPENEM | DrugsGivenReaction | CC BY-NC | 33503151 | 18,879,639 | 2021 |
Give an alphabetized list of all active substances of drugs taken by the patient who experienced 'Therapy non-responder'. | A case of round pneumonia due to Enterobacter hormaechei: the need for a standardized diagnosis and treatment approach in adults.
Round pneumonia is an unusual radiological manifestation of a bacterial lung infection. We present the case of an elderly male patient who arrived at the emergency room with a productive cough and exertional dyspnea. His chest x-ray and CT showed a round opacity and air bronchograms in the right upper lobe. Taken together, the patient's symptoms and images strongly suggest a pulmonary infection. Empirical antibiotic therapy with ceftriaxone and clarithromycin was started. The sputum culture was positive for Enterobacter hormaechei and the bacterium was sensitive to levofloxacin; therefore, the antibiotic therapy was changed. Despite the treatment, the patient progressed to respiratory failure and septic shock, dying six days after admission. Although round pneumonia is uncommon, it is a potentially curable disease and clinicians should always consider it in their differential diagnosis.
INTRODUCTION
Round pneumonia is an unusual radiological manifestation that varies from a small circular mass to a large undefined round opacity1. Only one percent of round pneumonia cases occur in adults2. Clinical presentations range from asymptomatic to a history of fever, productive cough and chills3,4. We report the case of an elderly adult admitted to the emergency room with exertional dyspnea.
CASE REPORT
A 64-year-old male with a history of alcohol consumption and liver cirrhosis arrived at the emergency department with a two-day history of productive cough and exertional dyspnea. The initial examination revealed a temperature of 36 °C, blood pressure 100/60 mmHg, heart rate 78 bpm and respiratory rate 19 bpm with an oxygen saturation of 96% in ambient air. On admission, a round opacity was observed in the right upper lobe on his chest X-ray (Figure 1). Laboratory tests were within normal ranges. Antibiotic therapy for community-acquired pneumonia was started with intravenous ceftriaxone and oral clarithromycin. The sputum culture was positive for E. hormaechei and the bacterium was sensitive to levofloxacin. Therapy was modified accordingly. Matrix-Assisted Laser Desorption Ionization–Time of Flight Mass Spectrometry analysis was used for the initial bacterial identification, while antimicrobial susceptibility testing was performed with the MicroScan WalkAway 96 plus system (Beckman Coulter Life Sciences, Indianapolis, IN, USA), proven by the Minimum Inhibitory Concentration (MIC), and interpretation/classification following the Clinical and Laboratory Standards Institute guidelines5 (Table 1).
Figure 1 (A) Well circumscribed opacity in the right upper lobe of the chest x-ray of our 64-year-old patient; (B) A focal round opacity with an air bronchogram at the upper lobe of the right lung on a chest CT scan was seen in our patient.
Table 1 Minimum inhibitory concentration (MIC) values of antimicrobial agents against E. hormaechei.
Antibiotic MIC Interpretation
Amikacin ≤ 16 Susceptible
Amoxicillin-clavulanate > 16/8 Resistant
ampicillin-sulbactam > 16/8 Resistant
Ampicillin > 16 Resistant
Cefazolin > 16 Resistant
Cefepime ≤ 4 Susceptible
Cefotaxime > 32 Resistant
Ceftazidime > 16 Resistant
Ceftriaxone > 32 Resistant
Cefuroxime > 16 Resistant
Ciprofloxacin ≤ 1 Susceptible
Ertapenem 1 Intermediate
Gentamicin ≤ 2 Susceptible
Imipenem/cilastatin ≤ 1 Susceptible
Levofloxacin ≤ 2 Susceptible
Meropenem ≤ 1 Susceptible
Piperacillin-tazobactam 32 Intermediate
Tetracycline ≤ 4 Susceptible
Tigecycline ≤ 2 Susceptible
Tobramycin ≤ 4 Susceptible
Trimethoprim-sulfamethoxazole ≤ 2/38 Susceptible
Forty-eight hours after presentation to the emergency room, the patient developed a systemic respiratory distress syndrome, was intubated and transferred to the intensive care unit. Mechanical ventilation with a lung-protective strategy was provided. During his ICU stay the patient developed hemodynamic instability. Additional blood cultures were drawn and there was a subsequent antibiotic therapy escalation with imipenem/cilastatin; however, the patient did not respond and died of septic shock.
DISCUSSION
Round pneumonia is a radiological and clinical entity described as the result of an infection that spreads centrifugally through the accessory connections between bronchioles and alveoli (canals of Lambert), between alveoli (pores of Kohn), or by destroying the acini walls. Another theory sustains that underdeveloped pores of Kohn and the absence of canals of Lambert limit the spread of the organism, resulting in a focal, round lesion in the lung1.
Physicians are obliged to differentiate between an infectious and a malignant etiology, which appears to be challenging in this presentation. An air bronchogram is found in 5- 50% of cases on CT scans in adults1; however, up to 65% of malignant nodules present with this same radiological pattern. Therefore, an air bronchogram does not seem to help distinguishing between round pneumonia and malignancy.
Wagner et al.1 reported that round pneumonia is more frequent in the lower lobe; accordingly, upper lobe lesions are especially suspicious of malignancy. It is important to note that, in contrast to what is reported in the existing literature, the predominance of these lesions in the upper lobe of the lung was found in the most contemporary review: nine (53.0%) cases in the upper lobes, six (35.3%) cases in the lower lobe and 2 (12.7%) cases in the middle lobe (Table 1). The predominance of the upper lobe has also been confirmed in this case. The mean age of patients of the cited studies is 45.2 years; this finding is similar to a previously reported case with a mean age of 40.93. This may help raising the suspicion that this is an infectious rather than a neoplastic process.
Infectious round infiltrates resolve over time, and the recommended assessment is through a repeated chest X-ray approximately eight weeks after treatment initiation6,7. However, studies in pediatric populations suggest that a follow-up chest X-ray is of limited value for those with a good response to medication8. Current practice guidelines of community-acquired pneumonia do not indicate the follow-up of patients with thoracic images if clinical improvement is evident, but recommendations for adults diagnosed with round pneumonia are not explicitly stated9.
Similar to patients with lobar pneumonia, the ideal antibiotic treatment should be directed against the most common bacterial pathogens (Streptococcus pneumoniae, Klebsiella pneumoniae, and Haemophilus influenza)4,10. However, some authors suggest that Q fever is currently the leading cause of round pneumonia in adults.
First-line therapy consists of doxycycline, but macrolides (erythromycin and clarithromycin) and quinolones (levofloxacin) are also curative and prevent the progression to chronic Q fever11. The duration of treatment for community-acquired pneumonia in current guidelines suggests a short 5-day course of antibiotics. Only patients without clinical improvement receive extended antibiotic therapy and further diagnostic approach9. Current antibiotic regimens for round pneumonia are typically long and highly heterogeneous, with duration ranging from 1 to 6 weeks (Table 2)3,4,12-24. In this regard, evidence-based recommendations on the duration of antibiotics in round pneumonia are needed. The pathogen identified in our case was E. hormaechei, which is a bacteria of the family Enterobacteriaceae that grows in most routine microbiological media and is identified by conventional tests25. Susceptibility testing can be performed using agar dilution, broth microdilution or disk diffusion. E. hormaechei is commonly susceptible to aminoglycosides, third-generation cephalosporins, carbapenems, and TMP/SMX, but resistant to aminopenicillins and penicillin G. According to a previous study, it is also susceptible to fluoroquinolones, but this finding contrasts with other reports26. Our patient had a poor clinical response to intravenous levofloxacin; for this reason, we switched to imipenem/cilastatin, but with no response. Risk factors for infection with Enterobacter spp. include immunosuppression, recent surgery, length of ICU stay, presence of an indwelling vascular or urinary catheter, and previous use of antibiotics26,27.
Table 2 Main clinical, radiological and treatment characteristics of case reports on round pneumonia over the last 20 years.
Articles Sex Age Risk factors Main complaint Chest image Subsequent image Antibiotic Treatment duration Bacterial pathogen Outcome
Gupta et al. 12
Female 29 None Fever and cough Chest X-ray and chest CT scan, right upper lobe ChestX-ray, 2 weeks Not specified 2 weeks Not identified Resolution
Yoshimura et al.
13
Male 43 History of recent travel Fever, fatigue, and headache Chest X-ray and chest CT scan, right lower lobe Not specified, 2 months minocycline 3 days
Rickettsia typhi
Resolution
Mahmood et al.14
Female 74 Current smoker and older age Dry cough and shortness of breathe Chest X-ray and chest CT scan, right lower lobe chest CT scan, 8 weeks Not specified Not specified
Streptococcus pneumoniae
Resolution
Harvey et al.
15
Female 70 Older age Fever, shortness of breathe, and productive cough Chest X-ray and chest CT scan, right upper lobe chest CT, not specified co-amoxiclav and clarithromycin Not specified Not identified Resolution
Cunha et al.16
Male 50 schizophrenia Cough, fever, myalgias, and shortness of breathe Chest X-ray, right upper lobe ChestX-ray, 8 weeks doxycycline 6 weeks Not identified Resolution
Köhne et al.
17
Male 55 Current smoker, seizures. Parkinson´s disease Fever and cough Chest X-ray and chest CT scan left upper lobe chest CT scan, 2 weeks ceftriaxone 2 weeks Not identified Resolution
Velasco-Tirado et al.
18
Male 58 zoonosis (cats) Fever, chills, headache, and abdominal pain Chest X-ray and chest CT scan, right upper lobe chest CT scan, 2 weeks doxycycline Not specified
Rickettsia typhi
Resolution
Velasco-Tirado et al.
18
Male 20 zoonosis (dog) Fever, dry cough, arthralgias, myalgias, headache, sweating and vomiting ChestX-ray , Right middle lobe ChestX-ray, 2 weeks doxycycline Not specified
Rickettsia typhi
Resolution
Kara et al.19
Female 26 None Fever and myalgia Chest X-ray and chest CT scan, Right middle lobe Not specified clarithromycin 10 days None. Resolution
Rodríguez20
Female 44 Current smoker, diabetes Fever, dyspnea, chest pain Chest X-ray and chest CT scan left lower lobe ChestX-ray, 1 week co-amoxiclav 7 days None Resolution
Jiménez-Castillo et al.21
Male 40 HIV infection Fever, headache, and fatigue Chest x-ray and chest CT scan left lower lobe Chest X-ray and chest CT scan, 4 days Co-trimoxazole 21 days
Pneumocystis jirovecii
Resolution
Violante-Cumpa et al.
22
Male 44 Diabetes and chronic kidney disease Dyspnea, orthopnea, and asthenia Chest X-ray h and chest CT scan left upper lobe Not specified Ceftriaxone and clarithromycin 7 days None Resolution
Zhang et al.23
Male 43 None Fever, chills, and cough Chest X-ray and chest CT scan left upper lobe chest CT scan, 2 weeks and 6 weeks Ceftriaxone and azithromycin 2 weeks none Resolution
Zylberman et al.
24
Female 24 None Fever and dry cough Chest X-ray and chest CT scan, right upper lobe. ChestX-ray, 1 week erythromycin 1 week
Chlamydia psittaci
Resolution
Zylberman et al.
24
Female 34 None Fever, dyspnea, and hemoptysis Chest X-ray and chest CT scan, right upper lobe Chest X-ray and chest CT scan, 1 week Ampicillin–sulbactam plus clarithromycin 11 days none Resolution
Durning et al.4
Female 58 None Fever, cough, and dyspnea. Chest X-ray left lower lobe ChestX-ray, 2 weeks Levofloxacin 14 days none Resolution
Camargo et al.3
Female 57 Current smoker Asymptomatic Chest X-ray right lower lobe ChestX-ray, 3 weeks none none Not applicable Resolution
Round pneumonia is an easily treatable infection as was corroborated by most of the cases reviewed here, but patients with abnormal immunity could progress rapidly to a life-threatening presentation10. We treated our patient according to bacterial susceptibility; despite this, his clinical evolution was unsatisfactory, potentially due to his history of liver cirrhosis, which has been associated with several abnormalities in innate and adaptive components of the immune system, leading to a state of acquired immunodeficiency and failure to resolve with standard therapy28. Laboratory tests for evaluation of cellular or antibody deficiencies were not available in our hospital at that moment.
The need for a standardized diagnosis and treatment approach in adults with round pneumonia is present. To the best of our knowledge, this is the first report on a case of round pneumonia due to E. hormaechei. There are several causes of oval lesions on chest images, however, clinicians should always have in mind this atypical presentation of a common disease.
ACKNOWLEDGMENTS
We thank Sergio Lozano-Rodriguez, MD, for his critical review of the manuscript. | CILASTATIN SODIUM\IMIPENEM | DrugsGivenReaction | CC BY-NC | 33503151 | 18,879,639 | 2021 |
What was the outcome of reaction 'Septic shock'? | A case of round pneumonia due to Enterobacter hormaechei: the need for a standardized diagnosis and treatment approach in adults.
Round pneumonia is an unusual radiological manifestation of a bacterial lung infection. We present the case of an elderly male patient who arrived at the emergency room with a productive cough and exertional dyspnea. His chest x-ray and CT showed a round opacity and air bronchograms in the right upper lobe. Taken together, the patient's symptoms and images strongly suggest a pulmonary infection. Empirical antibiotic therapy with ceftriaxone and clarithromycin was started. The sputum culture was positive for Enterobacter hormaechei and the bacterium was sensitive to levofloxacin; therefore, the antibiotic therapy was changed. Despite the treatment, the patient progressed to respiratory failure and septic shock, dying six days after admission. Although round pneumonia is uncommon, it is a potentially curable disease and clinicians should always consider it in their differential diagnosis.
INTRODUCTION
Round pneumonia is an unusual radiological manifestation that varies from a small circular mass to a large undefined round opacity1. Only one percent of round pneumonia cases occur in adults2. Clinical presentations range from asymptomatic to a history of fever, productive cough and chills3,4. We report the case of an elderly adult admitted to the emergency room with exertional dyspnea.
CASE REPORT
A 64-year-old male with a history of alcohol consumption and liver cirrhosis arrived at the emergency department with a two-day history of productive cough and exertional dyspnea. The initial examination revealed a temperature of 36 °C, blood pressure 100/60 mmHg, heart rate 78 bpm and respiratory rate 19 bpm with an oxygen saturation of 96% in ambient air. On admission, a round opacity was observed in the right upper lobe on his chest X-ray (Figure 1). Laboratory tests were within normal ranges. Antibiotic therapy for community-acquired pneumonia was started with intravenous ceftriaxone and oral clarithromycin. The sputum culture was positive for E. hormaechei and the bacterium was sensitive to levofloxacin. Therapy was modified accordingly. Matrix-Assisted Laser Desorption Ionization–Time of Flight Mass Spectrometry analysis was used for the initial bacterial identification, while antimicrobial susceptibility testing was performed with the MicroScan WalkAway 96 plus system (Beckman Coulter Life Sciences, Indianapolis, IN, USA), proven by the Minimum Inhibitory Concentration (MIC), and interpretation/classification following the Clinical and Laboratory Standards Institute guidelines5 (Table 1).
Figure 1 (A) Well circumscribed opacity in the right upper lobe of the chest x-ray of our 64-year-old patient; (B) A focal round opacity with an air bronchogram at the upper lobe of the right lung on a chest CT scan was seen in our patient.
Table 1 Minimum inhibitory concentration (MIC) values of antimicrobial agents against E. hormaechei.
Antibiotic MIC Interpretation
Amikacin ≤ 16 Susceptible
Amoxicillin-clavulanate > 16/8 Resistant
ampicillin-sulbactam > 16/8 Resistant
Ampicillin > 16 Resistant
Cefazolin > 16 Resistant
Cefepime ≤ 4 Susceptible
Cefotaxime > 32 Resistant
Ceftazidime > 16 Resistant
Ceftriaxone > 32 Resistant
Cefuroxime > 16 Resistant
Ciprofloxacin ≤ 1 Susceptible
Ertapenem 1 Intermediate
Gentamicin ≤ 2 Susceptible
Imipenem/cilastatin ≤ 1 Susceptible
Levofloxacin ≤ 2 Susceptible
Meropenem ≤ 1 Susceptible
Piperacillin-tazobactam 32 Intermediate
Tetracycline ≤ 4 Susceptible
Tigecycline ≤ 2 Susceptible
Tobramycin ≤ 4 Susceptible
Trimethoprim-sulfamethoxazole ≤ 2/38 Susceptible
Forty-eight hours after presentation to the emergency room, the patient developed a systemic respiratory distress syndrome, was intubated and transferred to the intensive care unit. Mechanical ventilation with a lung-protective strategy was provided. During his ICU stay the patient developed hemodynamic instability. Additional blood cultures were drawn and there was a subsequent antibiotic therapy escalation with imipenem/cilastatin; however, the patient did not respond and died of septic shock.
DISCUSSION
Round pneumonia is a radiological and clinical entity described as the result of an infection that spreads centrifugally through the accessory connections between bronchioles and alveoli (canals of Lambert), between alveoli (pores of Kohn), or by destroying the acini walls. Another theory sustains that underdeveloped pores of Kohn and the absence of canals of Lambert limit the spread of the organism, resulting in a focal, round lesion in the lung1.
Physicians are obliged to differentiate between an infectious and a malignant etiology, which appears to be challenging in this presentation. An air bronchogram is found in 5- 50% of cases on CT scans in adults1; however, up to 65% of malignant nodules present with this same radiological pattern. Therefore, an air bronchogram does not seem to help distinguishing between round pneumonia and malignancy.
Wagner et al.1 reported that round pneumonia is more frequent in the lower lobe; accordingly, upper lobe lesions are especially suspicious of malignancy. It is important to note that, in contrast to what is reported in the existing literature, the predominance of these lesions in the upper lobe of the lung was found in the most contemporary review: nine (53.0%) cases in the upper lobes, six (35.3%) cases in the lower lobe and 2 (12.7%) cases in the middle lobe (Table 1). The predominance of the upper lobe has also been confirmed in this case. The mean age of patients of the cited studies is 45.2 years; this finding is similar to a previously reported case with a mean age of 40.93. This may help raising the suspicion that this is an infectious rather than a neoplastic process.
Infectious round infiltrates resolve over time, and the recommended assessment is through a repeated chest X-ray approximately eight weeks after treatment initiation6,7. However, studies in pediatric populations suggest that a follow-up chest X-ray is of limited value for those with a good response to medication8. Current practice guidelines of community-acquired pneumonia do not indicate the follow-up of patients with thoracic images if clinical improvement is evident, but recommendations for adults diagnosed with round pneumonia are not explicitly stated9.
Similar to patients with lobar pneumonia, the ideal antibiotic treatment should be directed against the most common bacterial pathogens (Streptococcus pneumoniae, Klebsiella pneumoniae, and Haemophilus influenza)4,10. However, some authors suggest that Q fever is currently the leading cause of round pneumonia in adults.
First-line therapy consists of doxycycline, but macrolides (erythromycin and clarithromycin) and quinolones (levofloxacin) are also curative and prevent the progression to chronic Q fever11. The duration of treatment for community-acquired pneumonia in current guidelines suggests a short 5-day course of antibiotics. Only patients without clinical improvement receive extended antibiotic therapy and further diagnostic approach9. Current antibiotic regimens for round pneumonia are typically long and highly heterogeneous, with duration ranging from 1 to 6 weeks (Table 2)3,4,12-24. In this regard, evidence-based recommendations on the duration of antibiotics in round pneumonia are needed. The pathogen identified in our case was E. hormaechei, which is a bacteria of the family Enterobacteriaceae that grows in most routine microbiological media and is identified by conventional tests25. Susceptibility testing can be performed using agar dilution, broth microdilution or disk diffusion. E. hormaechei is commonly susceptible to aminoglycosides, third-generation cephalosporins, carbapenems, and TMP/SMX, but resistant to aminopenicillins and penicillin G. According to a previous study, it is also susceptible to fluoroquinolones, but this finding contrasts with other reports26. Our patient had a poor clinical response to intravenous levofloxacin; for this reason, we switched to imipenem/cilastatin, but with no response. Risk factors for infection with Enterobacter spp. include immunosuppression, recent surgery, length of ICU stay, presence of an indwelling vascular or urinary catheter, and previous use of antibiotics26,27.
Table 2 Main clinical, radiological and treatment characteristics of case reports on round pneumonia over the last 20 years.
Articles Sex Age Risk factors Main complaint Chest image Subsequent image Antibiotic Treatment duration Bacterial pathogen Outcome
Gupta et al. 12
Female 29 None Fever and cough Chest X-ray and chest CT scan, right upper lobe ChestX-ray, 2 weeks Not specified 2 weeks Not identified Resolution
Yoshimura et al.
13
Male 43 History of recent travel Fever, fatigue, and headache Chest X-ray and chest CT scan, right lower lobe Not specified, 2 months minocycline 3 days
Rickettsia typhi
Resolution
Mahmood et al.14
Female 74 Current smoker and older age Dry cough and shortness of breathe Chest X-ray and chest CT scan, right lower lobe chest CT scan, 8 weeks Not specified Not specified
Streptococcus pneumoniae
Resolution
Harvey et al.
15
Female 70 Older age Fever, shortness of breathe, and productive cough Chest X-ray and chest CT scan, right upper lobe chest CT, not specified co-amoxiclav and clarithromycin Not specified Not identified Resolution
Cunha et al.16
Male 50 schizophrenia Cough, fever, myalgias, and shortness of breathe Chest X-ray, right upper lobe ChestX-ray, 8 weeks doxycycline 6 weeks Not identified Resolution
Köhne et al.
17
Male 55 Current smoker, seizures. Parkinson´s disease Fever and cough Chest X-ray and chest CT scan left upper lobe chest CT scan, 2 weeks ceftriaxone 2 weeks Not identified Resolution
Velasco-Tirado et al.
18
Male 58 zoonosis (cats) Fever, chills, headache, and abdominal pain Chest X-ray and chest CT scan, right upper lobe chest CT scan, 2 weeks doxycycline Not specified
Rickettsia typhi
Resolution
Velasco-Tirado et al.
18
Male 20 zoonosis (dog) Fever, dry cough, arthralgias, myalgias, headache, sweating and vomiting ChestX-ray , Right middle lobe ChestX-ray, 2 weeks doxycycline Not specified
Rickettsia typhi
Resolution
Kara et al.19
Female 26 None Fever and myalgia Chest X-ray and chest CT scan, Right middle lobe Not specified clarithromycin 10 days None. Resolution
Rodríguez20
Female 44 Current smoker, diabetes Fever, dyspnea, chest pain Chest X-ray and chest CT scan left lower lobe ChestX-ray, 1 week co-amoxiclav 7 days None Resolution
Jiménez-Castillo et al.21
Male 40 HIV infection Fever, headache, and fatigue Chest x-ray and chest CT scan left lower lobe Chest X-ray and chest CT scan, 4 days Co-trimoxazole 21 days
Pneumocystis jirovecii
Resolution
Violante-Cumpa et al.
22
Male 44 Diabetes and chronic kidney disease Dyspnea, orthopnea, and asthenia Chest X-ray h and chest CT scan left upper lobe Not specified Ceftriaxone and clarithromycin 7 days None Resolution
Zhang et al.23
Male 43 None Fever, chills, and cough Chest X-ray and chest CT scan left upper lobe chest CT scan, 2 weeks and 6 weeks Ceftriaxone and azithromycin 2 weeks none Resolution
Zylberman et al.
24
Female 24 None Fever and dry cough Chest X-ray and chest CT scan, right upper lobe. ChestX-ray, 1 week erythromycin 1 week
Chlamydia psittaci
Resolution
Zylberman et al.
24
Female 34 None Fever, dyspnea, and hemoptysis Chest X-ray and chest CT scan, right upper lobe Chest X-ray and chest CT scan, 1 week Ampicillin–sulbactam plus clarithromycin 11 days none Resolution
Durning et al.4
Female 58 None Fever, cough, and dyspnea. Chest X-ray left lower lobe ChestX-ray, 2 weeks Levofloxacin 14 days none Resolution
Camargo et al.3
Female 57 Current smoker Asymptomatic Chest X-ray right lower lobe ChestX-ray, 3 weeks none none Not applicable Resolution
Round pneumonia is an easily treatable infection as was corroborated by most of the cases reviewed here, but patients with abnormal immunity could progress rapidly to a life-threatening presentation10. We treated our patient according to bacterial susceptibility; despite this, his clinical evolution was unsatisfactory, potentially due to his history of liver cirrhosis, which has been associated with several abnormalities in innate and adaptive components of the immune system, leading to a state of acquired immunodeficiency and failure to resolve with standard therapy28. Laboratory tests for evaluation of cellular or antibody deficiencies were not available in our hospital at that moment.
The need for a standardized diagnosis and treatment approach in adults with round pneumonia is present. To the best of our knowledge, this is the first report on a case of round pneumonia due to E. hormaechei. There are several causes of oval lesions on chest images, however, clinicians should always have in mind this atypical presentation of a common disease.
ACKNOWLEDGMENTS
We thank Sergio Lozano-Rodriguez, MD, for his critical review of the manuscript. | Fatal | ReactionOutcome | CC BY-NC | 33503151 | 18,879,639 | 2021 |
What was the outcome of reaction 'Therapy non-responder'? | A case of round pneumonia due to Enterobacter hormaechei: the need for a standardized diagnosis and treatment approach in adults.
Round pneumonia is an unusual radiological manifestation of a bacterial lung infection. We present the case of an elderly male patient who arrived at the emergency room with a productive cough and exertional dyspnea. His chest x-ray and CT showed a round opacity and air bronchograms in the right upper lobe. Taken together, the patient's symptoms and images strongly suggest a pulmonary infection. Empirical antibiotic therapy with ceftriaxone and clarithromycin was started. The sputum culture was positive for Enterobacter hormaechei and the bacterium was sensitive to levofloxacin; therefore, the antibiotic therapy was changed. Despite the treatment, the patient progressed to respiratory failure and septic shock, dying six days after admission. Although round pneumonia is uncommon, it is a potentially curable disease and clinicians should always consider it in their differential diagnosis.
INTRODUCTION
Round pneumonia is an unusual radiological manifestation that varies from a small circular mass to a large undefined round opacity1. Only one percent of round pneumonia cases occur in adults2. Clinical presentations range from asymptomatic to a history of fever, productive cough and chills3,4. We report the case of an elderly adult admitted to the emergency room with exertional dyspnea.
CASE REPORT
A 64-year-old male with a history of alcohol consumption and liver cirrhosis arrived at the emergency department with a two-day history of productive cough and exertional dyspnea. The initial examination revealed a temperature of 36 °C, blood pressure 100/60 mmHg, heart rate 78 bpm and respiratory rate 19 bpm with an oxygen saturation of 96% in ambient air. On admission, a round opacity was observed in the right upper lobe on his chest X-ray (Figure 1). Laboratory tests were within normal ranges. Antibiotic therapy for community-acquired pneumonia was started with intravenous ceftriaxone and oral clarithromycin. The sputum culture was positive for E. hormaechei and the bacterium was sensitive to levofloxacin. Therapy was modified accordingly. Matrix-Assisted Laser Desorption Ionization–Time of Flight Mass Spectrometry analysis was used for the initial bacterial identification, while antimicrobial susceptibility testing was performed with the MicroScan WalkAway 96 plus system (Beckman Coulter Life Sciences, Indianapolis, IN, USA), proven by the Minimum Inhibitory Concentration (MIC), and interpretation/classification following the Clinical and Laboratory Standards Institute guidelines5 (Table 1).
Figure 1 (A) Well circumscribed opacity in the right upper lobe of the chest x-ray of our 64-year-old patient; (B) A focal round opacity with an air bronchogram at the upper lobe of the right lung on a chest CT scan was seen in our patient.
Table 1 Minimum inhibitory concentration (MIC) values of antimicrobial agents against E. hormaechei.
Antibiotic MIC Interpretation
Amikacin ≤ 16 Susceptible
Amoxicillin-clavulanate > 16/8 Resistant
ampicillin-sulbactam > 16/8 Resistant
Ampicillin > 16 Resistant
Cefazolin > 16 Resistant
Cefepime ≤ 4 Susceptible
Cefotaxime > 32 Resistant
Ceftazidime > 16 Resistant
Ceftriaxone > 32 Resistant
Cefuroxime > 16 Resistant
Ciprofloxacin ≤ 1 Susceptible
Ertapenem 1 Intermediate
Gentamicin ≤ 2 Susceptible
Imipenem/cilastatin ≤ 1 Susceptible
Levofloxacin ≤ 2 Susceptible
Meropenem ≤ 1 Susceptible
Piperacillin-tazobactam 32 Intermediate
Tetracycline ≤ 4 Susceptible
Tigecycline ≤ 2 Susceptible
Tobramycin ≤ 4 Susceptible
Trimethoprim-sulfamethoxazole ≤ 2/38 Susceptible
Forty-eight hours after presentation to the emergency room, the patient developed a systemic respiratory distress syndrome, was intubated and transferred to the intensive care unit. Mechanical ventilation with a lung-protective strategy was provided. During his ICU stay the patient developed hemodynamic instability. Additional blood cultures were drawn and there was a subsequent antibiotic therapy escalation with imipenem/cilastatin; however, the patient did not respond and died of septic shock.
DISCUSSION
Round pneumonia is a radiological and clinical entity described as the result of an infection that spreads centrifugally through the accessory connections between bronchioles and alveoli (canals of Lambert), between alveoli (pores of Kohn), or by destroying the acini walls. Another theory sustains that underdeveloped pores of Kohn and the absence of canals of Lambert limit the spread of the organism, resulting in a focal, round lesion in the lung1.
Physicians are obliged to differentiate between an infectious and a malignant etiology, which appears to be challenging in this presentation. An air bronchogram is found in 5- 50% of cases on CT scans in adults1; however, up to 65% of malignant nodules present with this same radiological pattern. Therefore, an air bronchogram does not seem to help distinguishing between round pneumonia and malignancy.
Wagner et al.1 reported that round pneumonia is more frequent in the lower lobe; accordingly, upper lobe lesions are especially suspicious of malignancy. It is important to note that, in contrast to what is reported in the existing literature, the predominance of these lesions in the upper lobe of the lung was found in the most contemporary review: nine (53.0%) cases in the upper lobes, six (35.3%) cases in the lower lobe and 2 (12.7%) cases in the middle lobe (Table 1). The predominance of the upper lobe has also been confirmed in this case. The mean age of patients of the cited studies is 45.2 years; this finding is similar to a previously reported case with a mean age of 40.93. This may help raising the suspicion that this is an infectious rather than a neoplastic process.
Infectious round infiltrates resolve over time, and the recommended assessment is through a repeated chest X-ray approximately eight weeks after treatment initiation6,7. However, studies in pediatric populations suggest that a follow-up chest X-ray is of limited value for those with a good response to medication8. Current practice guidelines of community-acquired pneumonia do not indicate the follow-up of patients with thoracic images if clinical improvement is evident, but recommendations for adults diagnosed with round pneumonia are not explicitly stated9.
Similar to patients with lobar pneumonia, the ideal antibiotic treatment should be directed against the most common bacterial pathogens (Streptococcus pneumoniae, Klebsiella pneumoniae, and Haemophilus influenza)4,10. However, some authors suggest that Q fever is currently the leading cause of round pneumonia in adults.
First-line therapy consists of doxycycline, but macrolides (erythromycin and clarithromycin) and quinolones (levofloxacin) are also curative and prevent the progression to chronic Q fever11. The duration of treatment for community-acquired pneumonia in current guidelines suggests a short 5-day course of antibiotics. Only patients without clinical improvement receive extended antibiotic therapy and further diagnostic approach9. Current antibiotic regimens for round pneumonia are typically long and highly heterogeneous, with duration ranging from 1 to 6 weeks (Table 2)3,4,12-24. In this regard, evidence-based recommendations on the duration of antibiotics in round pneumonia are needed. The pathogen identified in our case was E. hormaechei, which is a bacteria of the family Enterobacteriaceae that grows in most routine microbiological media and is identified by conventional tests25. Susceptibility testing can be performed using agar dilution, broth microdilution or disk diffusion. E. hormaechei is commonly susceptible to aminoglycosides, third-generation cephalosporins, carbapenems, and TMP/SMX, but resistant to aminopenicillins and penicillin G. According to a previous study, it is also susceptible to fluoroquinolones, but this finding contrasts with other reports26. Our patient had a poor clinical response to intravenous levofloxacin; for this reason, we switched to imipenem/cilastatin, but with no response. Risk factors for infection with Enterobacter spp. include immunosuppression, recent surgery, length of ICU stay, presence of an indwelling vascular or urinary catheter, and previous use of antibiotics26,27.
Table 2 Main clinical, radiological and treatment characteristics of case reports on round pneumonia over the last 20 years.
Articles Sex Age Risk factors Main complaint Chest image Subsequent image Antibiotic Treatment duration Bacterial pathogen Outcome
Gupta et al. 12
Female 29 None Fever and cough Chest X-ray and chest CT scan, right upper lobe ChestX-ray, 2 weeks Not specified 2 weeks Not identified Resolution
Yoshimura et al.
13
Male 43 History of recent travel Fever, fatigue, and headache Chest X-ray and chest CT scan, right lower lobe Not specified, 2 months minocycline 3 days
Rickettsia typhi
Resolution
Mahmood et al.14
Female 74 Current smoker and older age Dry cough and shortness of breathe Chest X-ray and chest CT scan, right lower lobe chest CT scan, 8 weeks Not specified Not specified
Streptococcus pneumoniae
Resolution
Harvey et al.
15
Female 70 Older age Fever, shortness of breathe, and productive cough Chest X-ray and chest CT scan, right upper lobe chest CT, not specified co-amoxiclav and clarithromycin Not specified Not identified Resolution
Cunha et al.16
Male 50 schizophrenia Cough, fever, myalgias, and shortness of breathe Chest X-ray, right upper lobe ChestX-ray, 8 weeks doxycycline 6 weeks Not identified Resolution
Köhne et al.
17
Male 55 Current smoker, seizures. Parkinson´s disease Fever and cough Chest X-ray and chest CT scan left upper lobe chest CT scan, 2 weeks ceftriaxone 2 weeks Not identified Resolution
Velasco-Tirado et al.
18
Male 58 zoonosis (cats) Fever, chills, headache, and abdominal pain Chest X-ray and chest CT scan, right upper lobe chest CT scan, 2 weeks doxycycline Not specified
Rickettsia typhi
Resolution
Velasco-Tirado et al.
18
Male 20 zoonosis (dog) Fever, dry cough, arthralgias, myalgias, headache, sweating and vomiting ChestX-ray , Right middle lobe ChestX-ray, 2 weeks doxycycline Not specified
Rickettsia typhi
Resolution
Kara et al.19
Female 26 None Fever and myalgia Chest X-ray and chest CT scan, Right middle lobe Not specified clarithromycin 10 days None. Resolution
Rodríguez20
Female 44 Current smoker, diabetes Fever, dyspnea, chest pain Chest X-ray and chest CT scan left lower lobe ChestX-ray, 1 week co-amoxiclav 7 days None Resolution
Jiménez-Castillo et al.21
Male 40 HIV infection Fever, headache, and fatigue Chest x-ray and chest CT scan left lower lobe Chest X-ray and chest CT scan, 4 days Co-trimoxazole 21 days
Pneumocystis jirovecii
Resolution
Violante-Cumpa et al.
22
Male 44 Diabetes and chronic kidney disease Dyspnea, orthopnea, and asthenia Chest X-ray h and chest CT scan left upper lobe Not specified Ceftriaxone and clarithromycin 7 days None Resolution
Zhang et al.23
Male 43 None Fever, chills, and cough Chest X-ray and chest CT scan left upper lobe chest CT scan, 2 weeks and 6 weeks Ceftriaxone and azithromycin 2 weeks none Resolution
Zylberman et al.
24
Female 24 None Fever and dry cough Chest X-ray and chest CT scan, right upper lobe. ChestX-ray, 1 week erythromycin 1 week
Chlamydia psittaci
Resolution
Zylberman et al.
24
Female 34 None Fever, dyspnea, and hemoptysis Chest X-ray and chest CT scan, right upper lobe Chest X-ray and chest CT scan, 1 week Ampicillin–sulbactam plus clarithromycin 11 days none Resolution
Durning et al.4
Female 58 None Fever, cough, and dyspnea. Chest X-ray left lower lobe ChestX-ray, 2 weeks Levofloxacin 14 days none Resolution
Camargo et al.3
Female 57 Current smoker Asymptomatic Chest X-ray right lower lobe ChestX-ray, 3 weeks none none Not applicable Resolution
Round pneumonia is an easily treatable infection as was corroborated by most of the cases reviewed here, but patients with abnormal immunity could progress rapidly to a life-threatening presentation10. We treated our patient according to bacterial susceptibility; despite this, his clinical evolution was unsatisfactory, potentially due to his history of liver cirrhosis, which has been associated with several abnormalities in innate and adaptive components of the immune system, leading to a state of acquired immunodeficiency and failure to resolve with standard therapy28. Laboratory tests for evaluation of cellular or antibody deficiencies were not available in our hospital at that moment.
The need for a standardized diagnosis and treatment approach in adults with round pneumonia is present. To the best of our knowledge, this is the first report on a case of round pneumonia due to E. hormaechei. There are several causes of oval lesions on chest images, however, clinicians should always have in mind this atypical presentation of a common disease.
ACKNOWLEDGMENTS
We thank Sergio Lozano-Rodriguez, MD, for his critical review of the manuscript. | Fatal | ReactionOutcome | CC BY-NC | 33503151 | 18,879,639 | 2021 |
What was the dosage of drug 'PREDNISOLONE'? | Factors associated with COVID-19-related death in people with rheumatic diseases: results from the COVID-19 Global Rheumatology Alliance physician-reported registry.
To determine factors associated with COVID-19-related death in people with rheumatic diseases.
Physician-reported registry of adults with rheumatic disease and confirmed or presumptive COVID-19 (from 24 March to 1 July 2020). The primary outcome was COVID-19-related death. Age, sex, smoking status, comorbidities, rheumatic disease diagnosis, disease activity and medications were included as covariates in multivariable logistic regression models. Analyses were further stratified according to rheumatic disease category.
Of 3729 patients (mean age 57 years, 68% female), 390 (10.5%) died. Independent factors associated with COVID-19-related death were age (66-75 years: OR 3.00, 95% CI 2.13 to 4.22; >75 years: 6.18, 4.47 to 8.53; both vs ≤65 years), male sex (1.46, 1.11 to 1.91), hypertension combined with cardiovascular disease (1.89, 1.31 to 2.73), chronic lung disease (1.68, 1.26 to 2.25) and prednisolone-equivalent dosage >10 mg/day (1.69, 1.18 to 2.41; vs no glucocorticoid intake). Moderate/high disease activity (vs remission/low disease activity) was associated with higher odds of death (1.87, 1.27 to 2.77). Rituximab (4.04, 2.32 to 7.03), sulfasalazine (3.60, 1.66 to 7.78), immunosuppressants (azathioprine, cyclophosphamide, ciclosporin, mycophenolate or tacrolimus: 2.22, 1.43 to 3.46) and not receiving any disease-modifying anti-rheumatic drug (DMARD) (2.11, 1.48 to 3.01) were associated with higher odds of death, compared with methotrexate monotherapy. Other synthetic/biological DMARDs were not associated with COVID-19-related death.
Among people with rheumatic disease, COVID-19-related death was associated with known general factors (older age, male sex and specific comorbidities) and disease-specific factors (disease activity and specific medications). The association with moderate/high disease activity highlights the importance of adequate disease control with DMARDs, preferably without increasing glucocorticoid dosages. Caution may be required with rituximab, sulfasalazine and some immunosuppressants.
Key messages
What is already known about this subject?
To date, most available data on outcomes for people with rheumatic diseases infected with SARS-CoV-2 come from single centre or single country case series or from one large international registry; the COVID-19 Global Rheumatology Alliance (GRA) physician registry.
The first GRA publication identified factors associated with higher odds of COVID-19 hospitalisation, including older age, presence of comorbidities and higher dosages of glucocorticoids (≥10 mg/day of prednisolone equivalent).
Clinical outcome information on patients with COVID-19 who have rheumatic disease therefore remains limited, particularly with regard to factors associated with COVID-19-related death.
What does this study add?
In this analysis of 3729 patients with rheumatic diseases, older age, male sex, and cardiovascular and chronic lung disease were associated with COVID-19-related death.
Disease-specific factors, namely, moderate/high disease activity and certain medications (rituximab, sulfasalazine and immunosuppressants (as opposed to immunomodulators like disease-modifying anti-rheumatic drugs (DMARDs)) were also associated with COVID-19-related death.
How might this impact on clinical practice or future developments?
There is differential risk of COVID-19-related death according to disease activity and treatments in patients with rheumatic disease, highlighting the need for adequate disease control with DMARDs, preferably without increasing the glucocorticoid dosage.
Key messages
What is already known about this subject?
To date, most available data on outcomes for people with rheumatic diseases infected with SARS-CoV-2 come from single centre or single country case series or from one large international registry; the COVID-19 Global Rheumatology Alliance (GRA) physician registry.
The first GRA publication identified factors associated with higher odds of COVID-19 hospitalisation, including older age, presence of comorbidities and higher dosages of glucocorticoids (≥10 mg/day of prednisolone equivalent).
Clinical outcome information on patients with COVID-19 who have rheumatic disease therefore remains limited, particularly with regard to factors associated with COVID-19-related death.
What does this study add?
In this analysis of 3729 patients with rheumatic diseases, older age, male sex, and cardiovascular and chronic lung disease were associated with COVID-19-related death.
Disease-specific factors, namely, moderate/high disease activity and certain medications (rituximab, sulfasalazine and immunosuppressants (as opposed to immunomodulators like disease-modifying anti-rheumatic drugs (DMARDs)) were also associated with COVID-19-related death.
How might this impact on clinical practice or future developments?
There is differential risk of COVID-19-related death according to disease activity and treatments in patients with rheumatic disease, highlighting the need for adequate disease control with DMARDs, preferably without increasing the glucocorticoid dosage.
Introduction
There is a lack of robust data to inform our understanding of outcomes following SARS-CoV-2 infection in patients with inflammatory rheumatic diseases, leading to uncertainties regarding chronic disease management, especially for those taking immunosuppressant or immunomodulatory drugs.1–3
Whether people with rheumatic diseases belong to a vulnerable, higher risk population for SARS-CoV-2 infection and have poorer outcomes is unclear.1–8 In general, this population seems to have similar or only slightly poorer outcomes compared with those without rheumatic disease.7–9 However, important confounding disease-related factors, such as disease activity or treatments, have previously not been addressed.
Medications commonly used to treat rheumatic diseases have been used or are being tested for the prevention and/or treatment of COVID-19 and its complications,10 raising questions about the impact of these treatments on the outcomes of SARS-CoV-2 infection. Continuation of immunomodulatory or immunosuppressive therapy is essential for controlling rheumatic disease activity, avoiding disease progression and preventing joint or organ-damage related to sustained inflammation. Withdrawal of effective treatments should be based on sound evidence, even during a pandemic.
To generate more granular data relevant to rheumatic diseases, a global network of rheumatologists, data scientists and patients developed a COVID-19 physician-reported case registry in March 2020.11 12 Analysis of the first 600 patients revealed that older age and comorbidities were associated with hospitalisation,13 similar to results in the general population.8 14 More robust data on the risk of poor outcomes, in particular risk of death, are required.
The aim of this study was to investigate factors associated with COVID-19-related death in patients with rheumatic diseases and to analyse these associations by disease group.
Methods
Data source
The COVID-19 Global Rheumatology Alliance (C19-GRA) physician-reported registry is an observational registry launched on 24 March 2020. Data are entered voluntarily by rheumatologists or under supervision of rheumatologists; patients are eligible for inclusion if they have a pre-existing rheumatic disease and a COVID-19 diagnosis. Data are entered either directly into the global or European data entry systems or transferred from national registries (France, Germany, Italy, Portugal and Sweden).
We used data collected on or before 1 July 2020. Further details of this registry have been described elsewhere.11–13 Countries were assigned to the six WHO regions (www.who.int); the ‘Americas’ was further divided into north and south. Given the registry collects anonymous data, the UK Health Research Authority and the University of California San Francisco Institutional Review Board considered it exempt from patient consent.
Patient stratification into diagnostic groups
Rheumatic diseases differ regarding the disease-modifying antirheumatic drugs (DMARDs) approved for their treatment. To minimise the impact of this heterogeneity on the associations of interest, in addition to the main analysis with all patients, diagnostic categories were defined (figure 1) and stratified analyses were undertaken for patients with (1) inflammatory joint diseases (IJD), (2) rheumatoid arthritis (a subset of the IJD subgroup) and (3) connective tissue diseases (CTD)/vasculitis.
Figure 1 Disease and medication groups. ANCA, anti-neutrophil cytoplasm antibodies; DMARD, disease-modifying antirheumatic drugs; IgG, immunoglobulin; IL, interleukin; JAK, Janus kinase; TNF, tumour necrosis factor.
COVID-19 reporting and outcome
Both confirmed and presumptive cases of COVID-19 were reported. The method of COVID-19 diagnosis was specified: PCR, CT scan, metagenomic testing, laboratory assays or based on symptoms only.
For analysis, patients were subsequently categorised into (1) confirmed or high likelihood of COVID-19 (chest imaging (CT or chest X-ray) showing bilateral infiltrates and/or symptoms after close contact with a known laboratory-confirmed COVID-19 positive patient) or (2) presumptive cases based on symptoms alone.
The primary outcome was COVID-19-related death.
Treatment prior to COVID-19
Antirheumatic medications used prior to COVID-19 diagnosis were categorised into groups shown in figure 1. Immunomodulatory drugs (conventional synthetic (cs)/biological (b)/targeted synthetic (ts) DMARDs) were distinguished from immunosuppressive drugs (azathioprine, cyclophosphamide, ciclosporin, mycophenolate mofetil/mycophenolic acid, tacrolimus) as recommended by Isaacs and Burmester15; glucocorticoids are also immunosuppressive but they were examined separately and categorised by prednisolone-equivalent dosage (1–10 mg/day and >10 mg/day). Methotrexate monotherapy was adopted as the medication reference group; methotrexate is the anchor drug in multiple rheumatic diseases16 and it represents the largest medication category in the registry.
Statistical analyses
Descriptive tables were produced for the whole cohort and then by diagnostic group, country (for the six countries with the highest number of cases: France, Germany, Italy, Spain, UK and USA) and medication. Independent associations between demographic and disease features and COVID-19-related death were estimated using multivariable logistic regression and reported as OR and 95% CI. Covariates included in the model were age, sex, key comorbidities (hypertension alone or cardiovascular disease (CVD) alone, hypertension combined with CVD, chronic lung disease, chronic kidney disease (CKD) and diabetes), smoking status (ever vs never), rheumatic disease diagnostic group, disease activity as per the physician’s global assessment (severe/high or moderate disease activity vs minimal/low disease activity or remission), rheumatic disease treatment prior to COVID-19 diagnosis and prednisolone-equivalent glucocorticoid use.
All patients with confirmed or presumptive COVID-19 were included in the main analyses. Patients with missing primary outcome (N=82) or missing values for age, sex and DMARD (N=19) were excluded from analysis. Missing values for comorbidities, smoking status, glucocorticoid therapy and disease activity were derived by multiple imputation using full conditional specification.17 Results of the logistic regression analyses for 10 imputed datasets were pooled by Rubin’s rules. As disease activity was missing for all French patients, country-level life expectancy was used in the imputation model to explain potential structural differences in disease activity between countries not accounted for in the patient-level data (data from 2018, source: http://hdr.undp.org/).
To account for pronounced heterogeneity between participating countries regarding both healthcare systems and infection dynamics, countries were implicitly considered as data clusters in the regression analysis by assuming that the data arose from a cluster sample design; this was done by applying a Taylor series linearisation in the variance estimation.18
For patients listed as having more than one rheumatic disease or being treated with more than one of the medications of interest, we created a hierarchy based on clinical expertise to categorise patients. This process creates disjoint categories, allowing a clear reference group for interpretation of the regression models and avoiding collinearities. Patients with more than one of the following diseases were grouped according to the following hierarchy: systemic lupus erythematosus (SLE)>vasculitis>other CTD>RA>psoriatic arthritis (PsA)>(other) spondyloarthritis (SpA)>other IJD>other non-IJD/non-CTD rheumatic disease. Patients receiving multiple csDMARDs or immunosuppressants (except glucocorticoids) were grouped according to the following hierarchy: immunosuppressants>sulfasalazine>antimalarials>leflunomide>methotrexate. Patients receiving a b/tsDMARD were considered solely in the b/tsDMARD group. Patients treated with more than one b/tsDMARD (N=4), patients receiving IL-1 inhibitors (N=20) and patients receiving DMARDs atypical for their disease subgroup (N=48) were excluded from analysis due to very low numbers (figure 2). Patients were excluded from a particular analysis if the medication they received provided ≤20 patients for that analysis or if there were no deaths reported for that specific medication.
Figure 2 Patient flowchart. Some patients had diagnoses in multiple groups; as a result, the sum of patients in each group is greater than the total number of patients. (*) Patients belonging to more than one diagnosic group: IJD and CTD: N=78 (10 deaths); IJD and other: N=70 (12 deaths); CTD and other: N=50 (13 deaths); IJD and CTD and other: N=5 (2 deaths). (§) Patients belonging to more than one diagnosic group: IJD and CTD: N=77 (10 deaths); IJD and other: N=70 (12 deaths); CTD and other: N=49 (12 deaths); IJD and CTD and other: N=5 (2 deaths). (#) Patients belonging to more than one diagnosic group: IJD and CTD: N=59 (7 deaths). (**) Non-typical DMARDs for IJD and RA: immunosuppressants and belimumab; non-typical DMARDs for RA: IL-17/IL-23/IL-12+23 inhibitors. (***) Non-typical DMARDs for CTD: abatacept, IL-17/IL-23/IL-12+23 inhibitors, sulfasalazine, leflunomide and tsDMARDs. b/tsDMARDs, biological/targeted synthetic disease-modifying antirheumatic drugs; CTD, connective tissue disease/vasculitis; DMARDs, disease-modifying anti-rheumatic drugs; IJD, inflammatory joint disease; IL, interleukin; RA, rheumatoid arthritis.
The following sensitivity analyses were performed to examine the robustness of our findings to procedures for handling missing data: (1) excluding patients from France (no disease activity data available); (2) complete case analysis. Further sensitivity analyses were conducted to assess the stability of the results: (1) limited to patients with confirmed or highly likely COVID-19; (2) using the alternative outcome ‘death or invasive ventilation’; (3) using a reduced number of covariates to assess the risk of overfitting; (4) analysis explicitly controlling for country, using data from the top six reporting countries; (5) analysis stratified for several binary key variables (age >65 or not, sex, ever smoked vs not, high/moderate/severe disease activity vs remission/low disease activity, CVD, chronic lung disease, glucocorticoid use) to assess the possibility of interactions.
Data were considered statistically significant for p values <0.05. All analyses were conducted in SAS (V.9.4) and R (V.3.6.3).
Results
As of 1 July 2020, 3830 patients were in the registry, of whom 3729 had no missing values for death, age, sex and DMARD therapy (table 1, results for all patients; online supplemental table 1, results stratified by diagnostic subgroup; online supplemental table 2, results stratified by country; online supplemental table 3, results stratified by medication of interest).
10.1136/annrheumdis-2020-219498.supp1 Supplementary data
Table 1 Patient demographic and clinical characteristics
Parameter Not deceased Deceased Total
N 3339 390 3729
General
Age (years) 55.5 (15.2) 69.7 (14.6) 57.0 (15.7)
≤30 197 (5.9) 9 (2.3) 206 (5.5)
31–50 1012 (30.3) 31 (7.9) 1043 (28)
51–65 1255 (37.6) 82 (21) 1337 (35.9)
66–75 536 (16.1) 109 (27.9) 645 (17.3)
>75 339 (10.2) 159 (40.8) 498 (13.4)
Male sex 1031 (30.9) 164 (42.1) 1195 (32)
Ever smoker 664 (23.3)
(N=2854)
(Missing=485) 112 (36.1)
(N=310)
(Missing=80) 776 (24.5)
(N=3164)
(Missing=565)
Regions
African region 14 (0.4) 2 (0.5) 16 (0.4)
Eastern Mediterranean region 83 (2.5) 11 (2.8) 94 (2.5)
European region 2040 (61.1) 275 (70.5) 2315 (62.1)
North American region 1024 (30.7) 81 (20.8) 1105 (29.6)
South American region 112 (3.4) 10 (2.6) 122 (3.3)
South-East Asian region 11 (0.3) 0 11 (0.3)
Western Pacific region 55 (1.6) 11 (2.8) 66 (1.8)
Inflammatory joint diseases
Rheumatoid arthritis 1224 (36.7) 170 (43.6) 1394 (37.4)
Spondyloarthritis 416 (12.5) 15 (3.8) 431 (11.6)
Psoriatic arthritis 420 (12.6) 20 (5.1) 440 (11.8)
Juvenile idiopathic arthritis (poly, oligo, not systemic) 21 (0.6) 4 (1) 25 (0.7)
Other inflammatory arthritis 90 (2.7) 8 (2.1) 98 (2.6)
Total Inflammatory joint diseases 2158 (64.6) 215 (55.1) 2373 (63.6)
Connective tissue diseases/Vasculitis
Systemic lupus erythematosus 355 (10.6) 36 (9.2) 391 (10.5)
Connective tissue diseases (other than SLE) 473 (14.2) 60 (15.4) 533 (14.3)
Vasculitis 258 (7.7) 68 (17.4) 326 (8.7)
Total CTD 1035 (31) 158 (40.5) 1193 (32.0)
Other RMDs
Total 306 (9.2) 50 (12.8) 356 (9.5)
Disease activity N=2464
(Missing=875) N=294
(Missing=96) N=2758
(Missing=971)
Remission 799 (32.4) 94 (32) 893 (32.4)
Minimal/low disease activity 1202 (48.8) 107 (36.4) 1309 (47.5)
Moderate disease activity 388 (15.7) 60 (20.4) 448 (16.2)
Severe/high disease activity 75 (3) 33 (11.2) 108 (3.9)
Other outcomes
Hospitalised 1368 (43.3)
(N=3162)
(Missing=177) 371 (96.6)
(N=384)
(Missing=6) 1739 (49)
(N=3546)
(Missing=183)
Invasive ventilation 67 (2.5)
(N=2701)
(Missing=638) 120 (40.8)
(N=294)
(Missing=96) 187 (6.2)
(N=2995)
(Missing=734)
Comorbidities N=3314
(Missing=25) N=386
(Missing=4) N=3700
(Missing=29)
Hypertension 1095 (33) 212 (54.9) 1307 (35.3)
Cardiovascular disease 318 (9.6) 124 (32.1) 442 (11.9)
Cerebrovascular disease 89 (2.7) 20 (5.2) 109 (2.9)
Chronic lung disease 581 (17.5) 138 (35.8) 719 (19.4)
Chronic kidney disease 181 (5.5) 77 (19.9) 258 (7)
Obesity (BMI ≥30) 539 (16.3) 58 (15) 597 (16.1)
Morbid obesity (BMI ≥40) 106 (3.2) 16 (4.1) 122 (3.3)
Diabetes 410 (12.4) 95 (24.6) 505 (13.6)
Cancer 165 (5) 49 (12.7) 214 (5.8)
Other comorbidities 771 (23.3) 126 (32.6) 897 (24.2)
Number of comorbities 1.3 (1.3) 2.5 (1.6) 1.4 (1.3)
No comorbidity 1090 (32.9) 28 (7.3) 1118 (30.2)
One comorbidity 1032 (31.1) 83 (21.5) 1115 (30.1)
Two comorbidities 597 (18) 110 (28.5) 707 (19.1)
≥3 comorbidites 595 (18) 165 (42.7) 760 (20.5)
DMARD therapies
csDMARDs monotherapy 592 (17.7) 59 (15.1) 651 (17.5)
csDMARDs combination therapy 692 (20.7) 61 (15.6) 753 (20.2)
Methotrexate monotherapy 531 (15.9) 47 (12.1) 578 (15.5)
Methotrexate combination therapy 607 (18.2) 52 (13.3) 659 (17.7)
Leflunomide monotherapy 61 (1.8) 12 (3.1) 73 (2)
Leflunomide combination therapy 120 (3.6) 10 (2.6) 130 (3.5)
Sulfasalazine monotherapy 51 (1.5) 16 (4.1) 67 (1.8)
Sulfasalazine combination therapy 129 (3.9) 26 (6.7) 155 (4.2)
Antimalarial monotherapy 287 (8.6) 17 (4.4) 304 (8.2)
Antimalarial combination therapy 322 (9.6) 39 (10) 361 (9.7)
Immunosuppressants monotherapy 149 (4.5) 26 (6.7) 175 (4.7)
Immunosuppressants combination therapy 147 (4.4) 21 (5.4) 168 (4.5)
Mycophenolate mofetil monotherapy 68 (2) 14 (3.6) 82 (2.2)
Mycophenolate mofetil combination therapy 81 (2.4) 15 (3.8) 96 (2.6)
Azathioprine monotherapy 63 (1.9) 7 (1.8) 70 (1.9)
Azathioprine combination therapy 51 (1.5) 3 (0.8) 54 (1.4)
Cyclophosphamide monotherapy 10 (0.3) 3 (0.8) 13 (0.3)
Cyclophosphamide combination therapy 5 (0.1) 5 (1.3) 10 (0.3)
Tacrolimus monotherapy 5 (0.1) 2 (0.5) 7 (0.2)
Tacrolimus combination therapy 11 (0.3) 0 11 (0.3)
Ciclosporin monotherapy 3 (0.1) 0 3 (0.1)
Ciclosporin combination therapy 11 (0.3) 1 (0.3) 12 (0.3)
bDMARDs monotherapy 675 (20.2) 48 (12.3) 723 (19.4)
bDMARDs combination therapy 562 (16.8) 46 (11.8) 608 (16.3)
TNF inhibitors monotherapy 434 (13) 13 (3.3) 447 (12)
TNF inhibitors combination therapy 340 (10.2) 17 (4.4) 357 (9.6)
Abatacept monotherapy 28 (0.8) 4 (1) 32 (0.9)
Abatacept combination therapy 46 (1.4) 5 (1.3) 51 (1.4)
B-cell-targeted bDMARDs monotherapy 71 (2.1) 25 (6.4) 96 (2.6)
B-cell-targeted bDMARDs combination therapy 106 (3.2) 18 (4.6) 124 (3.3)
Rituximab monotherapy 66 (2) 25 (6.4) 91 (2.4)
Rituximab combination therapy 85 (2.5) 17 (4.4) 102 (2.7)
Belimumab monotherapy 5 (0.1) 0 5 (0.1)
Belimumab combination therapy 22 (0.7) 1 (0.3) 23 (0.6)
IL-6 inhibitors monotherapy 51 (1.5) 3 (0.8) 54 (1.4)
IL-6 inhibitors combination therapy 34 (1) 2 (0.5) 36 (1)
IL-1 inhibitors monotherapy 10 (0.3) 2 (0.5) 12 (0.3)
IL-1 inhibitors combination therapy 4 (0.1) 4 (1) 8 (0.2)
IL-17, IL-23, IL-12/23 inhibitors monotherapy 79 (2.4) 1 (0.3) 80 (2.1)
IL-17, IL-23, IL-12/23 inhibitors combination therapy 36 (1.1) 0 36 (1)
tsDMARDs monotherapy 61 (1.8) 5 (1.3) 66 (1.8)
tsDMARDs (*) combination therapy 71 (2.1) 10 (2.6) 81 (2.2)
JAK inhibitors monotherapy 54 (1.6) 4 (1) 58 (1.6)
JAK inhibitors combination therapy 67 (2) 9 (2.3) 76 (2)
Apremilast monotherapy 7 (0.2) 1 (0.3) 8 (0.2)
Apremilast combination therapy 3 (0.1) 1 (0.3) 4 (0.1)
No DMARD therapies 615 (18.4) 124 (31.8) 739 (19.8)
Further therapies
Glucocorticoids (#) 1056 (32)
(N=3302)
(Missing=37) 217 (57.1)
(N=380)
(Missing=10) 1273 (34.6)
(N=3682)
(Missing=47)
Glucocorticoids 1–10 mg/day 833 (25.6)
(N=3254)
(Missing=85) 150 (41.3)
(N=363)
(Missing=27) 983 (27.2)
(N=3617)
(Missing=112)
Glucocorticoids>10 mg/day 171 (5.3)
(N=3254)
(Missing=85) 49 (13.5)
(N=363)
(Missing=27) 220 (6.1)
(N=3617)
(Missing=112)
NSAIDs 600 (19.3)
(N=3103)
(Missing=236) 38 (11.0)
(N=345)
(Missing=45) 638 (18.5)
(N=3448)
(Missing=281)
Data are N (column %) for categorical variables or mean (SD) for continuous variables. The table includes all patients with a non-missing outcome and non-missing values for age, sex and disease-modifying anti-rheumatic drugs (DMARDs) (101 patients excluded). Data refer to patients with non-missing values for the respective variable; total N for patients with non-missing values is given in parentheses for variables with missing values; the total number of missing values is also given in parenthesis, for the applicable variables. (*) Includes one patient on a study medication (Lenabasum). (#) Includes patients with a missing glucocorticoid dosage.
bDMARD, biological disease-modifying antirheumatic drug; BMI, body mass index; csDMARD, conventional synthetic disease-modifying antirheumatic drug; CTD, connective tissue diseases; DMARD, disease-modifying antirheumatic drug; IL, interleukin; JAK, Janus kinase; JIA, juvenile idiopathic arthritis; N, number; NSAID, non-steroidal anti-inflammatory drugs; SLE, systemic lupus erythematosus; TNF, tumour necrosis factor; tsDMARD, targeted synthetic disease-modifying antirheumatic drug.
Patient characteristics and outcomes of COVID-19
Mean age was 57 (15.7) years and most patients were ≤65 years (2586/3729, 69.3%) and female (2534/3729, 68%). The most common disease was RA (1394/3729, 37.4%), followed by CTDs other than SLE (533/3729, 14.3%), SLE (391/3729, 10.5%), PsA (440/3729, 11.8%) and other SpA (431/3729, 11.6%).
Patients were primarily from Europe (2315/3729, 62.1%) or North America (1105/3729, 29.6%). Nearly half (1309/2758, 47.5%) had minimal or low disease activity and one-third (893/2758, 32.4%) were in remission before COVID-19. One-quarter of all patients (776/3164, 24.5%) were ever smokers.
Most patients had a laboratory-confirmed diagnosis of COVID-19 (2897/3729, 77.7%); 2.4% (91/3729) had a high likelihood of infection based on imaging or confirmed COVID-19 contacts.
Death occurred in 10.5% (390/3729) of patients; 68.7% (268/390) of those who died were >65 years. Nearly half of all patients (1739/3546; 49.0%) were hospitalised. Invasive ventilation was reported in 6.2% (187/2995) of patients, but in 40.8% (120/294) of those who died.
Comorbidities
Most patients (2582/3700, 69.8%) had at least one comorbidity, and 20.5% (760/3700) had more than three. The most frequent were hypertension (1307/3700, 35.3%), chronic lung disease (719/3700, 19.4%), obesity (BMI ≥30; 597/3700, 16.1%), diabetes (505/3700, 13.6%), other CVD (442/3700, 11.9%) and CKD (258/3700, 7.0%). Among deceased patients, the proportion of those with comorbidities was higher, with 42.7% (165/386) having ≥3 comorbidities, namely, 54.9% (212/386) with hypertension, 35.8% (138/386) with chronic lung disease, 24.6% (95/386) with diabetes, 32.1% (124/386) with other CVD and 19.9% (77/386) with CKD.
Treatments
At the time of COVID-19 diagnosis, 40.6% (1514/3729) of patients were treated only with csDMARDs, immunosuppressants or combinations of these; 35.7% (1331/3729) received bDMARDs and 3.9% (147/3729) received tsDMARDs. One-fifth (739/3729, 19.8%) were not receiving any DMARD/immunosuppressive treatment (except glucocorticoids), and this proportion was higher among deceased patients (124/390, 31.8%).
Among the patients not receiving any DMARD/immunosuppressive treatment, 39.8% (290/729) received glucocorticoids, 9.8% (70/712) with a prednisolone-equivalent dosage of >10 mg/day; the most frequent diagnostic categories being other non-specified rheumatic diseases (173/739, 23.4%), vasculitis (161/739, 21.8%), CTD other than SLE (156/739, 21.1%) and RA (110/739, 14.9%).
Country-specific differences
The majority of cases (2993/3729, 80.3%) were reported from six countries with considerable differences in reported percentages of death (online supplemental table 2). Overall, 10.5% (390/3729) of patients died, with highest proportions in the UK (91/435, 20.9%) and Italy (53/315, 16.8%). Death was reported in lower proportions in the USA (70/1005, 7.0%), Germany (15/198, 7.6%), France (62/793, 7.8%) and Spain (21/247, 8.5%). Other major differences between the countries were the distribution of rheumatic diseases and the distribution and frequency of comorbidities.
Factors associated with death
In multivariable analyses (table 2, figure 3), patients between 66 and 75 years of age were more likely to have died (OR 3.00, 95% CI 2.13 to 4.22) than those ≤65 years. The association was even more pronounced in patients over 75 years (6.18, 4.47 to 8.53; vs ≤65 years). Male sex was also associated with higher odds of death (1.46, 1.11 to 1.91). Current or former smoking was only associated with death in the RA subgroup (1.45, 1.02 to 2.04).
Figure 3 Results of the main logistic regression analysis. Shown are multivariable-adjusted ORs for the outcome COVID-19-related death with 95% CIs, assessing the association with (A) general patient characteristics, (B) comorbidities, (C) rheumatic disease diagnoses (RMD) and (D) rheumatic disease medications. ORs are shown for four groups: all patients (black), patients with inflammatory joint disease (red), patients with rheumatoid arthritis (orange), and patients with a connective tissue disease or vasculitis (blue). For (C), only ORs for all patients are shown. The reference categories are as follows: (A) ≤65 years, females, never smoked, remission or low disease activity; (B) the non-presence of the specific comorbidities (for all effects); (C) rheumatoid arthritis (for all effects); (D) methotrexate monotherapy (for all effects except for glucocorticoids), no glucocorticoids (for glucocorticoid dosage groups). Patients receiving multiple csDMARDs or immunosuppressants (except glucocorticoids) were grouped according to the following hierarchy: immunosuppressants>sulfasalazine>antimalarials>leflunomide>methotrexate; patients receiving a b/tsDMARD were considered solely in the b/tsDMARD group; glucocorticoids were examined separately and categorised by prednisolone-equivalent dosage (1–10 mg/day and >10 mg/day). bDMARD, biological disease-modifying anti-rheumatic drug; csDMARD, conventional synthetic disease-modifying antirheumatic drug; CTD, connective tissue diseases; CVD, cardiovascular disease; JIA, juvenile idiopathic arthritis; tsDMARD, targeted synthetic disease-modifying anti-rheumatic drug.
Table 2 Multivariable logistic regression analysis of factors associated with COVID-19-related death in patients with rheumatic diseases (all patients)
N deaths/patients (%) All Patients with inflammatory joint diseases (IJDs) Only patients with rheumatoid arthritis Patients with connective tissue diseases (CTDs) or vasculitis
384/3705 (10.4%) 211/2348 (9.0%) 166/1371 (12.1%) 147/1157 (12.7%)
N deaths/patients OR 95% CI N deaths/patients OR 95% CI N deaths/patients OR 95% CI N deaths/patients OR 95% CI
Age, years
Age≤65 118/2565 1 Reference 55/1657 1 Reference 40/840 1 Reference 56/779 1 Reference
65 years<Age≤75 109/644 3 2.13 to 4.22 71/426 3.63 2.55 to 5.15 55/314 3.10 1.68 to 5.72 33/187 2.29 1.34 to 3.93
Age>75 157/496 6.18 4.47 to 8.53 85/265 8.21 5.54 to 12.18 71/217 7.30 4.42 to 12.06 58/191 4.08 2.27 to 7.36
Male sex (vs female) 161/1188 1.46 1.11 to 1.91 82/788 1.31 0.95 to 1.8 55/345 1.17 0.78 to 1.76 63/296 1.66 0.96 to 2.86
Ever smoked (vs never) 140/922 1.21 0.94 to 1.57 84/607 1.26 0.93 to 1.72 71/385 1.45 1.02 to 2.04 42/248 1.11 0.67 to 1.86
Comorbidities
Hypertension alone or CVD alone 155/1150 1.19 0.89 to 1.59 79/690 1.04 0.74 to 1.46 66/454 1.11 0.74 to 1.67 69/406 1.56 1.06 to 2.29
Hypertension and CVD 89/301 1.89 1.31 to 2.73 53/168 2.29 1.25 to 4.23 38/118 2.03 1.03 to 3.97 28/106 1.57 0.78 to 3.16
Chronic lung disease 136/721 1.68 1.26 to 2.25 76/406 1.52 1.04 to 2.21 63/293 1.44 0.99 to 2.09 54/285 2.05 1.47 to 2.85
Chronic kidney disease 76/259 1.67 0.99 to 2.8 27/111 1.09 0.54 to 2.21 21/83 1.01 0.46 to 2.24 41/124 2.30 1.37 to 3.88
Diabetes mellitus 96/508 1.38 0.88 to 2.17 55/313 1.31 0.95 to 1.79 39/213 1.08 0.72 to 1.61 32/154 1.39 0.64 to 3
Rheumatic disease
Rheumatoid arthritis 160/1326 1 Reference 166/1373 1 Reference n.a. n.a.
Systemic lupus erythematosus 36/391 1.2 0.70 to 2.04 n.a. n.a. 32/378 1 Reference
Vasculitis 67/325 0.8 0.60 to 1.08 n.a. n.a. 64/318 0.81 0.49 to 1.33
Other connective tissue diseases 53/473 0.75 0.58 to 0.97 n.a. n.a. 51/461 0.78 0.39 to 1.54
Psoriasis arthritis 19/429 0.75 0.53 to 1.07 19/437 0.82 0.55 to 1.22 n.a. n.a.
Spondyloarthritis 15/423 0.72 0.34 to 1.54 15/424 0.82 0.4 to 1.69 n.a. n.a.
Other inflammatory arthritis or non-systemic JIA 10/109 0.79 0.46 to 1.34 11/114 0.76 0.43 to 1.36 n.a. n.a.
Other rheumatic diseases (not IJDs/CTDs/vasculitis) 24/229 0.51 0.35 to 0.73 n.a. n.a. n.a.
High/moderate/severe disease activity (DA) vs remission/low DA 109/722 1.87 1.27 to 2.77 54/453 1.6 1.13 to 2.26 44/274 1.60 1.03 to 2.47 51/230 2.45 1.49 to 4.02
Medication
Methotrexate 47/595 1 Reference 41/487 1 Reference 34/354 1 Reference 6/94 1 Reference
No DMARD therapy 124/739 2.11 1.48 to 3.01 38/239 2.08 1.38 to 3.14 25/110 2.12 1.34 to 3.37 67/353 3.18 1.61 to 6.27
Leflunomide 12/90 1.56 0.9 to 2.7 10/83 1.37 0.69 to 2.73 9/68 1.43 0.71 to 2.86 n.a.
Antimalarials 27/426 0.99 0.66 to 1.48 17/167 1.14 0.65 to 2 17/141 1.24 0.7 to 2.19 11/271 1.38 0.48 to 4.02
Sulfasalazine 33/144 3.6 1.66 to 7.78 31/137 3.40 1.46 to 7.93 21/85 2.62 1.21 to 5.68 n.a.
Immunosuppressants 38/276 2.22 1.43 to 3.46 n.a. n.a. 32/247 2.44 1.06 to 5.65
TNF inhibitors 30/803 0.85 0.52 to 1.36 26/764 0.77 0.42 to 1.41 16/292 0.82 0.39 to 1.76 4/39 2.00 0.36 to 11.2
Abatacept 9/81 1.20 0.61 to 2.34 9/75 1.3 0.62 to 2.71 9/68 1.4 0.65 to 2.99 n.a.
Rituximab 42/192 4.04 2.32 to 7.03 22/90 5.42 2.77 to 10.61 21/86 4.99 2.43 to 10.26 22/104 3.72 1.21 to 11.48
Belimumab 1/27 0.71 0.19 to 2.68 n.a. n.a. 1/27 1.07 0.21 to 5.37
IL-6 inhibitors 5/90 0.83 0.38 to 1.84 1/68 0.25 0.03 to 2.43 1/63 0.25 0.03 to 2.33 4/23 2.69 0.88 to 8.19
IL-17/IL-23/IL-12+23 inhibitors 1/115 0.25 0.03 to 2.04 1/112 0.26 0.03 to 2.06 n.a. n.a.
tsDMARDs 15/145 1.60 0.91 to 2.8 15/142 1.75 0.99 to 3.12 13/118 1.57 0.75 to 3.27 n.a.
Glucocorticoids (GCs)
No GCs 165/2417 1 Reference 109/1721 1 Reference 78/863 1 Reference 38/551 1 Reference
GCs 1–10 mg/day 170/1062 1.43 0.98 to 2.09 89/567 1.36 0.76 to 2.45 78/464 1.34 0.66 to 2.74 75/469 1.69 1.11 to 2.57
GCs>10 mg/day 49/226 1.69 1.18 to 2.41 12/60 1.55 0.67 to 3.57 10/44 1.59 0.6 to 4.18 34/137 1.93 1.11 to 3.36
Missing values were imputed via multiple imputation, patient numbers may thus be rounded. Effects significant at level α=0.05 are marked in bold. Patients were excluded from a particular analysis if the medication they received provided ≤20 patients for that analysis or if there were no deaths reported for that specific medication.
TNF; tumour necrosis factor; CTD, connective tissue diseases; CVD, cardiovascular duisease; DMARD, disease-modifying antirheumatic drugs; GC, glucocorticoids; IL, interleukin; JIA, juvenile idiopathic arthritis; N, number; n.a., not applicable; tsDMARD, targeted synthetic disease-modifying antirheumatic drugs.
Other factors associated with death included chronic lung disease (1.68, 1.26 to 2.25) and CVD combined with hypertension (1.89, 1.31 to 2.73), whereas hypertension or CVD alone did not show a significant association. CKD was significantly associated with death in patients with CTD or vasculitis (2.30, 1.37 to 3.88) but not in other disease subgroups.
Across all diagnostic groups, treatments with leflunomide, antimalarials, TNF inhibitors, abatacept, belimumab, IL-6 inhibitors, IL-17/IL-23/IL-12+23 inhibitors and tsDMARDs were not associated with death, as compared with methotrexate monotherapy. In the overall model, not receiving DMARD treatment was associated with death (2.11, 1.48 to 3.01) compared with methotrexate monotherapy. This was also seen in the IJD, RA and CTD subgroups.
Compared with methotrexate monotherapy, treatments associated with a higher odds of death were rituximab (4.04, 2.32 to 7.03, in the overall model; 5.42, 2.77 to 10.61, in the IJD subgroup; 4.99, 2.43 to 10.26, in the RA subgroup; 3.72, 1.21 to 11.48, in the CTD/vasculitis subgroup), sulfasalazine (3.60, 1.66 to 7.78, in the overall model and consistent across all subgroups) and immunosuppressants (azathioprine, cyclophosphamide, ciclosporin, mycophenolate or tacrolimus: 2.22, 1.43 to 3.46, in the overall model; 2.44, 1.06 to 5.65, in the CTD/vasculitis subgroup; not applicable to other subgroups).
An additional analysis indicated that the association of sulfasalazine with an increased odds for death was mainly driven by the larger group of sulfasalazine monotherapy and persisted even when sulfasalazine combination treatment (plus either antimalarials, leflunomide or methotrexate) was considered separately (data not shown).
Treatment with higher dosages of glucocorticoids (>10 mg/day prednisolone-equivalent dose vs no use) was also found to be associated with death (1.69, 1.18 to 2.41), particularly in the CTD/vasculitis subgroup (1.93, 1.11 to 3.36).
Higher disease activity at COVID-19 diagnosis was consistently associated with death across all disease groups. Patients with high/moderate/severe disease activity had higher odds of death (1.87, 1.27 to 2.77) than patients with low disease activity or in remission (overall model and consistent across all subgroups).
Sensitivity analyses
Results were largely consistent in our sensitivity analyses (online supplemental tables 4–9). In the complete case analysis (online supplemental table 5), the association between sulfasalazine and death was no longer statistically significant. In stratified analyses (online supplemental tables 10–16), sulfasalazine use was not associated with death among patients that never smoked, with the OR among ever smokers being almost threefold than among non-smokers (online supplemental table 12).
Discussion
With global cooperation, the C19-GRA physician-reported registry is the largest collection to date of patients with rheumatic diseases and COVID-19. We found that moderate/high disease activity was significantly associated with COVID-19-related death, confirming recent recommendations regarding the importance of disease control in rheumatic diseases in the COVID-19 era.1 Other factors associated with death were older age, male sex and the presence of comorbidities, which is consistent with reports from the general population.8 Overall, compared with methotrexate monotherapy, most DMARDs were not associated with higher odds of death, although rituximab and sulfasalazine were notable exceptions. Prednisolone-equivalent dosages >10 mg/day and other immunosuppressive drugs (as opposed to immunomodulatory DMARDs) were also associated with COVID-19-related death.
In this cohort of patients with underlying rheumatic diseases, the COVID-19-related death rate was 10.5%, clearly higher than that reported in the general population in most countries. However, this study was not designed to calculate a precise point estimate for mortality. Reporting biases and population-related factors, including COVID-19 testing rates, could explain this figure and, importantly, it should not be taken as an estimate of the overall death rate among patients with rheumatic diseases and COVID-19.
The association of rituximab with poorer COVID-19-related outcomes is a previously unreported finding outside of case reports. Rituximab binds to CD20 on the surface of B-cells, effectively depleting this cell type, and interferes with antibody development. Therefore, B-cell depletion could potentially compromise antiviral immunity, including the development of SARS-CoV-2 antibodies.19 With our data, it was not possible to determine the exact timing of infection following rituximab infusion, although all patients were clinically judged by their rheumatologist to have been exposed to the immunological effects of the drug at the time of COVID-19 diagnosis. The association between rituximab and COVID-19-related death could have also been influenced by the typical coadministration of methylprednisolone with rituximab.
A finding that merits further research is the higher odds of death found with sulfasalazine treatment. This association has also been reported in results from an international registry of patients with inflammatory bowel disease and COVID-19, where sulfasalazine or 5-aminosalicylate (5-ASA) use was associated with severe COVID-19 (adjusted OR of 3.1 (1.3 to 7.7)).20 This finding is surprising as sulfasalazine is usually considered to have a low immunosuppressive effect. Prior research supports an immune regulatory effect driven by sulfasalazine or its metabolite 5-ASA against other RNA viruses.21–24 However, causal interpretation of the association between sulfasalazine and COVID-19-related death should not be made. The perceived low immunosuppressive effect of sulfasalazine may have led rheumatologists to prescribe preferentially sulfasalazine over methotrexate in patients who were perceived to be at higher risk, for example, patients with pulmonary disease, smoking or recurrent chest infections. In an observational study like ours, this could lead to unmeasured confounding. A salient difference in sulfasalazine users in our study was a higher proportion of current or former smokers, compared with non-users. In the stratified analyses for chronic lung disease, the association between death and sulfasalazine was significant in both subgroups with and without chronic lung disease, while in the stratified analyses for smoking, the association between death and sulfasalazine was limited to ever smokers, so the factor ‘smoking’ could potentially be an effect modifier. Another potential explanation for this finding could be the merging of sulfasalazine combination therapy (with other csDMARDs) with sulfasalazine monotherapy; however, the increased odds for death persisted in the sulfasalazine monotherapy group and was not driven by the combination treatment (data not shown).
Despite the large overall sample size, for some therapies (eg, IL-6 and IL-17/IL-23/IL-12+23 inhibitors) the number of users was low and no firm conclusions could be made. IL-6 inhibitors have been used to counteract the hyperinflammatory state produced by COVID-19, with mostly disappointing randomised trial results.25 26 Their efficacy is still being investigated in ongoing trials, but it is reassuring that they were not associated with COVID-19-related death in our analyses. Previous studies had shown an association between TNF inhibitors and a decreased risk of sepsis and mortality in patients with RA after serious infection compared with csDMARDs.27 28 We could not confirm such an association after stratification by disease and adjustment for disease activity. However, the data indicate that some associations may exist among patients diagnosed with IJD other than RA (a subgroup comprising predominantly patients with axial SpA and PsA), in whom male sex and diabetes mellitus were associated with a higher odds of death, and TNF inhibitor use was associated with a lower odds of death (univariable analysis, data not shown). Due to a small number of deceased patients in this subgroup with non-RA subtypes of IJD (n=37 deaths), these effects could not be assessed in a multivariable model and this should be investigated in the future when higher case numbers allow a more stable assessment.
This study has limitations. As a cross-sectional, case-reporting registry, it may be subject to selection bias if more severe cases are more likely to come to the rheumatologists’ attention and therefore to be reported. There is an absence of a population-based comparator, and we are unable to make comparisons between those with and without COVID-19. Moreover, we caution against interpreting our estimates causally. There is likely unmeasured confounding dependent on the particularities of health systems and case reporting differences. We tried to address this by limiting the research questions to those that could be answered with this dataset and by accounting for potential confounders in our analyses. The high number of variables compared with outcome events in the subgroup models may result in biased estimates.29 30 However, the consistency between the main model and the sensitivity analyses (including using a lower number of variables) do not indicate an issue with overfitting.
In conclusion, people with rheumatic diseases with higher disease activity have higher odds of COVID-19-related death, highlighting the importance of disease control, preferably by managing DMARDs effectively without increasing glucocorticoids. Future studies should address the observed association of rituximab and sulfasalazine with poor outcomes. Finally, as in the general population, older age, male sex and/or the presence of comorbidities increase the odds of COVID-19-related death.
We wish to thank all rheumatology providers who entered data into the registry.
Data availability statement
Data are available upon reasonable request. Applications to access the data should be made to the C19-GRA Steering Committee.
Ethics statements
Patient consent for publication
Not required.
Ethics approval
The C19-GRA physician-reported registry was determined “not human subjects’ research” by the UK Health Research Authority and the University of Manchester, as well as under United States Federal Guidelines assessed by the University of California San Francisco Institutional Review Board.
Handling editor: Josef S Smolen
Twitter: @rheum_cat, @rthritis, @emilysirotich, @zach_wallace_md, @carmona_loreto, @hausmannmd, @philipcrobinson, @pedrommcmachado
AS and MS contributed equally.
PCR, JY and PMM contributed equally.
Correction notice: This article has been corrected since it published Online First. The collaborator names have been updated.
Collaborators: COVID-19 Global Rheumatology Alliance Consortium: Brahim Dahou (Association Rhumatologues Algériens Privés; Algeria), Marcelo Pinheiro (Universidade Federal De São Paulo Escola Paulista de Medicina e Escola Paulista de Enfermagem; Brazil), Francinne M Ribeiro (Hospital Universitário Pedro Ernesto Universidade do Estado do Rio de Janeiro; Brazil), Anne-Marie Chassin-Trubert (Complejo Hospitalario San José; Chile), Sebastián Ibáñez (Clínica Alemana de Santiago, Chile), Lingli Dong (Tongji Hospital, China)
Lui Cajas (Clinica Universitaria Colombia - Centro Medico Providencia Sanitas; Colombia), Hesham Hamoud (Al Azhar University Hospitals; Egypt), Jérôme Avouac (Rheumatology A Department, Cochin University Hospitals Paris-Centre, AP-HP; France), Véronique Belin (Department of Rheumatology, Hospital Center of Thonon-les-Bains; France), Raphaël Borie (Department of Pneumology, Bicha Hospital, AP-HP; France), Pascal Chazerain (Department of Rheumatology and Internal Medicine, Diaconesses Croix Saint Simon Hospital, Paris; France), Xavier Chevalier (Department of Rheumatology, Henri Mondor University Hospitals, AP-HP, Créteil; France), Pascal Claudepierre (Department of Rheumatology, Henri Mondor University Hospitals, AP-HP, Créteil; France), Gaëlle Clavel (Department of Internal Medicine, Rothschild Foundation, Paris; France), Marie-Eve Colette-Cedoz (Nord-Isère Rheumatology practice, Bourgoin-Jallieu; France), Bernard Combe (Department of Rheumatology, Lapeyronie University Hospital of Montpellier France), Elodie Constant (Department of Rheumatology, Hospital Center of Valence; France), Nathalie Costedoat-Chalumeau (Department of Internal Medicine, Cochin University Hospitals Paris-Centre, AP-HP; France), Marie Desmurs (Department of Rheumatology, Mulhouse-South Alsace hospital group; France), Valérie Devauchelle-Pensec (Rheumatology Department, Cavale Blanche Hospital and Brest Occidentale University; France), Mathilde Devaux (Department of Internal Medicine, Intercommunal Hospital Center of Poissy-Saint Germain; France), Robin Dhote (Department of Internal Medicine, Avicenne University Hospital, AP-HP, Paris; France), Yannick Dieudonné (Department of Internal Medicine and Clinical Immunology, Strasbourg University Hospital; France), Fanny Domont (Department of Internal Medicine and Clinical Immunology, Pitié-Salpêtrière Hospital, AP-HP; France), Pierre-Marie Duret (Department of Rheumatology, Colmar Civil Hospitals; France), Mikaël Ebbo (Department of Internal Medicine, La Timone Hospital, Aix-Marseille Univerity, AP-HM; France), Esther Ebstein (Department of Rheumatology, Bicha Hospital, AP-HP; France), Soumaya El Mahou (Department of Rheumatology and Internal Medicine, Hospital Center of Tourcoing; France), Bruno Fautrel (Department of Rheumatology, University Hospital Pitie Salpetriere, AP-HP, Paris; France), Renaud Felten (Department of Rheumatology, University Hospital of Strasbourg; France), René-Marc Flipo (Department of Rheumatology, University Hospital of Lille; France), Violaine Foltz (Department of Rheumatology, University Hospital Pitie Salpetriere, AP-HP; France), Antoine Froissart (Department of Internal Medicine, Intercommunal Hospital Center of Créteil; France), Joris Galland (Department of Internal Medicine, Lariboisière University Hospital, AP-HP, Paris; France), Véronique Gaud-Listrat (Rheumatology practice, Saint-Michel-sur-Orge; France), Sophie Georgin-Lavialle (Department of Internal Medicine, Tenon Hospital, AP-HP; France), Aude Giraud-Morelet (Val d'Ouest Clinical Medicine Center; France), Jeanine S Giraudet-Le Quitrec (Rheumatology A Department, Cochin University Hospitals Paris-Centre, AP-HP; France), Philippe Goupille (Department of Rheumatology, University Hospital of Tours; France), Sophie Govindaraju-Audouard (Rheumatology practice Les Haberges, Vesoul; France), Franck Grados (Department of Rheumatology, Amiens University Hospital; France), Séverine Guillaume-Czitrom (Department of Adolescent Medicine, University Hospital Paris-Sud, AP-HP, Le Kremlin-Bicêtre; France), Marion Hermet (Department of Internal Medicine, Hospital Center of Vichy; France), Ambre Hittinger-Roux (Department of Rheumatology, University Hospital of Reims; France), Christophe Hudry (Institute of Rheumatology Paris 8; France), Isabelle Kone-Paut (Department of Paediatric Rheumatology, University Hospital Paris-Sud, AP-HP, Le Kremlin-Bicêtre; France), Sylvain La Batide Alanore (Rheumatology practice, Paris; France), Pierre Lafforgue (Department of Rheumatology, Sainte-Marguerite Hospital, Aix-Marseille Univerity, AP-HM; France), Sophie Lahalle (Department of Rheumatology and Internal Medicine, Diaconesses Croix Saint Simon Hospital, Paris; France), Isabelle Lambrecht (Department of Rheumatology, Maison-Blanche Hospital, Reims University Hospitals; France), Vincent Langlois (Department of Infectious Diseases and Internal Medicine, Jacques Monod Hospital, Le Havre; France), Jean-Paul Larbre (Department of Rheumatology, Lyon-Sud Hospital, Hospices Civils Lyon; France), Emmanuel Ledoult (Department of Internal Medicine, Hospital Center of Tourcoing; France), Christophe Leroux (Department of Polyvalent Medicine, Dreux Hospital center; France), Frédéric Liote (Department of Rheumatology, Lariboisière University Hospital, AP-HP, Paris; France), Alexandre TJ Maria (Department of Internal Medicine and Multiorganic Diseases, Saint-Eloi University Hospital of Montpellier; France), Hubert Marotte (Department of Rheumatology, Saint-Etienne University Hospital; France), Arsène Mekinian (Department of Internal Medicine, Saint-Antoine Hospital, AP-HP, Paris; France), Isabelle Melki (Paediatric Hematology-Immunology and Rheumatology Department, Necker-Enfants-Malades University Hospital, AP-HP;France), Laurent Messer (Department of Rheumatology, Colmar Civil Hospitals; France), Catherine Michel (Department of Dermatology, Mulhouse-South Alsace hospital group; France), Gauthier Morel (Department of Rheumatology, Hospital Center of Valencienne; France), Jacques Morel (Department of Rheumatology, Lapeyronie University Hospital of Montpellier; France), Marie-Noelle Paris-Havard (Department of Rheumatology, Hospital Center of Argenteuil; France), Edouard Pertuiset (Department of Rheumatology, René Dubos Hospital Center, Pontoise; France), Thao Pham (Department of Rheumatology, Sainte-Marguerite Hospital, Aix-Marseille Univerity, AP-HM; France), Myriam Renard (Department of Rheumatology, Hospital Center of Aix-les-Bains, France), Sabine Revuz (Department of Internal Medicine and Clinical Immunology, Metz private Hospitals; France), Sébastien Rivière (Department of Internal Medicine and Inflammation-Immunopathology-Biotherapy, Saint-Antoine Hospital, AP-HP, Paris; France), Clémentine Rousselin (Department of Internal Medicine and Nephrology, Hospital Center of Valencienne; France), Christian Roux (Department of Rheumatology, Pasteur 2 University Hospital of Nice Sophia-Antipolis; France), Diane Rouzaud (Department of Internal Medicine, Bicha Hospital, AP-HP; France), Jérémie Sellam (Department of Rheumatology, Saint-Antoine Hospital, AP-HP, Paris; France), Raphaele Seror (Department of Rheumatology, University Hospitals Paris-Sud, AP-HP, Le Kremlin-Bicêtre; France), Amelie Servettaz (Department of Internal Medicine, University Hospital of Reims; France), Vincent Sobanski (Department of Internal Medicine and Clinical Immunology, University Hospital of Lille; France), Christelle Sordet (Department of Rheumatology, University Hospital of Strasbourg; France), Lionnel Spielmann (Department of Rheumatology, Colmar Civil Hospitals; France), Nathalie Tieulié (Department of Rheumatology, Pasteur 2 University Hospital of Nice Sophia-Antipolis; France), Alice Tison (Department of Rheumatology, University Hospital of Bordeaux; France), Sophie Trijau (Department of Rheumatology, Sainte-Marguerite Hospital, Aix-Marseille Univerity, AP-HM; France), Alexandre Virone (Department of Rheumatology, University Hospitals Paris-Sud, AP-HP, Le Kremlin-Bicêtre; France), Ursula Warzocha (Department of Internal Medicine, Avicenne University Hospital, AP-HP, Paris; France), Daniel Wendling (Department of Rheumatology, University Hospital of Besançon; France), Frederik N Albach (Department of Rheumatology and Clinical Immunology, Charité Universitätsmedizin, Berlin; Germany), Peer Aries (Rheumatology Struensee-Haus, Hamburg; Germany), Elvira Decker (Medical Care Center, Alsfeld; Germany), Urs Hartmann (Private Practice, Mainz; Germany), Joerg Henes (Department of Internal Medicine II, University of Tubingen; Germany), Bimba F Hoyer (University Hospital Schleswig-Holstein - Campus Kiel, Department of Rheumatology and Clinical Immunology, Clinic for Internal Medicine I; Germany), Andreas Krause (Immanuel Hospital Berlin, Department of Rheumatology, Clinical Immunology and Osteology; Germany), Klaus Krüger (Private Practice, Munich; Germany), Hanns-Martin Lorenz (University of Heidelberg, Department of Rheumatology; Germany), Ulf Müller-Ladner (Campus Kerckhoff, Justus-Liebig-University Giessen, Department of Rheumatology and Clinical Immunology; Germany), Alexander Pfeil (Department of Internal Medicine III, University Hospital Jena; Germany), Anne Regierer (German Rheumatism Research Center Berlin; Germany), Jutta G Richter (Heinrich-Heine-University, Medical Faculty, Department of Rheumatology and Hiller Research Unit; Germany), Markus Rihl (Private Practice, Traunstein; Germany), Tim Schmeiser (Private Practice, Cologne; Germany), Hendrik Schulze-Koops (University of Munich, Division of Rheumatology and Clinical Immunology, Department of Internal Medicine IV; Germany), Christof Specker (KEM Kliniken Essen-Mitte, Department of Rheumatology and Clinical Immunology; Germany), Reinhard E Voll (University Medical Center Freiburg, Department of Rheumatology and Clinical Immunology; Germany), Stephanie Werner (RHIO, Dusseldorf; Germany), Gabriela MG Melgar (Hospital del Valle; Honduras), Mahdi Vojdanian (Iran Rheumatology Center; Iran), Laura Andreoli (UO di Reumatologia ed Immunologia Clinica, Spedali Civili di Brescia; Italy), Elena Bartoloni-Bocci (University of Perugia; Italy), Maurizio Benucci (Ospedale civile San Giovanni di Dio; Italy), Francesco Campanaro (ASST Sette Laghi, Varese; Italy), Marta Caprioli (Rheumatology, Humanitas Clinical and Research Center – IRCCS; Italy), Davide Carboni (Azienda ospedaliero-universitaria Careggi; Italy), Greta Carrara (Italian Society for Rheumatology; Italy), Edoardo Cipolletta (Università Politecnica delle Marche; Italy), Chiara Crotti (ASST Gaetano Pini; Italy), Gloria Dallagiacoma (Ospedale di Brunico; Italy), Paola Faggioli (ASST ovest milanese legnano; Italy), Rosario Foti (Policlinico-Vitt. Emanuele; Policinico San Marco; Italy), Franco Franceschini (UO di Reumatologia ed Immunologia Clinica, Spedali Civili di Brescia Italy), Micaela Fredi (UO di Reumatologia ed Immunologia Clinica, Spedali Civili di Brescia; Italy), Giacomo Guidelli (Rheumatology, Humanitas Clinical and Research Center – IRCCS; Italy), Florenzo Iannone (University of Bari; Italy), Gianpiero Landolfi (Italian Society for Rheumatology; Italy), Caludia Lomater (Azienda Ospedaliera Ordine Mauriziano di Torino; Italy), Ceciclia Nalli (UO di Reumatologia ed Immunologia Clinica, Spedali Civili di Brescia; Italy), Simone Parisi (AOU Città della Salute e della Scienza; Italy), Luca Quartuccio (Università degli Studi di Udine; Italy), Bernd Raffeiner (Ospedale di Bolzano; Italy), Rossella Reggia (Ospedale Maggiore di Cremona; Italy), Marta Riva (Ospedale San Gerardo di Monza; Italy), Nicoletta Romeo (Azienda Ospedaliera Santa Croce e Carle di Cuneo; Italy), Cinzia Rotondo (Azienda Ospedaliero-Universitaria "Ospedali Riuniti" di Foggia; Italy), Ettore Silvagni (University of Ferrara; Italy), Luigi Sinigaglia (Italian Society for Rheumatology; Italy), Ilaria Tinazzi (Ospedale Sacro Cuore don Calabria di Negrar a Verona; Italy), Anna Zanetti (Italian Society for Rheumatology; Italy), Giovanni Zanframundo (Fondazione IRCCS Policlinico San Matteo di Pavia; Italy), Fatemah Abutiban (Kuwait Rheumatology Association; Kuwait), Deshiré Alpízar-Rodríguez (Mexican College of Rheumatology; Mexico), Marina Rull-Gabayet (Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán; Mexico), Fedra Irazoque (Private Practice; Mexico), Xochitl Jimenez (Centro Medico Naval; Mexico), Eduardo Martín-Nares (Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán; Mexico), Angel Castillo-Ortiz (Centro Medico Las Americas; Mexico), Tatiana S Rodriguez-Reyna (Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán; Mexico), Diana C Rosete (Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán; Mexico), Erick A Zamora-Tehozol (Centro Medico Pensiones; Mexico), David Vega-Morales (Hospital General de Zona #17; Mexico), Beatriz Elena Zaueta-Montiel (Centro Medico del Angel; Mexico), Rebecca Grainger (University of Otago, Wellington; New Zealand), Nasra Al-Adhoubi (Royal Hospital; Oman), Babur Salim (Fauji Foundation Hospital; Pakistan), Enrique Giraldo (Complejo Hospitalario; Panama), Ariel Salinas (Hospital Essalud Alberto Sabogal Sologuren; Peru), Manuel Ugarte-Gil (Universidad Científica del Sur-Hospital Guillermo Almenara Irigoyen; Peru), Diogo Almeida (Rheumatology Department, Unidade Local de Saúde do Alto Minho, Ponte de Lima; Portugal), Miguel Bernardes (Rheumatology Department, Centro Hopitalar São João, Porto; Portugal), Rita C Machado (Rheumatology and Metabolic Bone Diseases Department, Hospital de Santa Maria, CHLN, Lisbon Academic Medical Centre, Lisboa; Portugal), Maria Rato (Rheumatology Department, Centro Hopitalar São João, Porto; Portugal), Samar Al-Emadi (Hamad Medical Corporation; Qatar), Richard Conway (St. James's Hospital; Republic of Ireland), Rachael Flood (Tallaght University Hospital; Republic of Ireland), Juan J Alegre-Sancho (Hospital Universitari Dr Peset; Spain), Montserrat C Coro (complejo asistencial de Ávila; Spain), Natalia de la Torre-Rubio (Hospital Universitario Puerta de Hierro Majadahonda; Spain), Jose C Esteban (Hospital Universitario Puerta de Hierro; Spain), Maria del Carmen T Martin (HOSPITAL NUESTRA SEÑORA SONSOLES; Spain), Jose G Puerta (Hospital Clinic; Spain), Johan Back (Uppsala University Hospital, Uppsala; Sweden), Maryam Dastmalchi (Karolinska University Hospital, Stockholm; Sweden), Brigitte Dupré (Academic Specialist Center, Stockholm; Sweden), Emma Grenholm (Falu Lasarett, Region Dalarna, Falun; Sweden), Aase Hensvold (Academic Specialist Center, Stockholm; Sweden), Ann Knight (Uppsala University Hospital, Uppsala; Sweden), Servet Akar (Izmir Katip Celebi University Atatürk Training and Research Hospital; Turkey), Ozan C Icacan (Bakırköy Dr. Sadi Konuk Research and Training Hospital; Turkey), Laura Chadwick (St Helens & Knowsley NHS Trust; UK), Kirsty Devine (York Hospital; UK), Sasha Dunt (Countess of Chester NHS Foundation Trust; UK), Lucia Fusi (King's College Hospital; UK), Caroline M Jones (Llandudno Hospital; UK), Elizabeth Macphie (Lancashire and South Cumbria NHS Foundation Trust; UK), Elena Nikiphorou (King's College Hospital; UK), Diana O'Kane (Royal National Hospital For Rheumatic Diseases at Royal United Hospital; UK), Sheila O'Reilly (Royal Derby Hospital; UK), Samir Patel (Queen Elizabeth hospital; UK), Rosaria Salerno (King's College Hospital; UK), Lucy Thornton (Bradford Royal Infirmary; UK), Jenny Tyler (Royal United Hospital, Bath; UK), Claire Vandevelde (Leeds Teaching Hospitals Trust; UK), Elizabeth Warner (Lister Hospital; UK), Su-Ann Yeoh (University College London Hospitals NHS Foundation Trust; UK), Sara Baig (Arthritis and Rheumatology Consultants, PA; USA), Hammad Bajwa (Arthritis and Rheumatology Consultants, PA; USA), Byung Ban (Medstar Georgetown University Hospital; USA), Vernon Berglund (Arthritis and Rheumatology Consultants, PA; USA), Cassandra Calabrese (Cleveland Clinic; USA), Kristin D'Silva (Brigham and Women's Hospital; USA), Angela Dahle (Arthritis and Rheumatology Consultants, PA; USA), Kathryn Dao (UT Southwestern Medical Center; USA), Nicole Daver (Institute of Rheumatic and Autoimmune Diseases; USA), William Davis (Ochsner Medical Center Rheumatology Department; USA), Walter Dorman (Arthritis and Rheumatology Consultants, PA; USA), Ezzati Fatemeh (UT Southwestern Medical Center; USA), Theodore Fields (Hospital for Special Surgery; USA), Jody Hargrove (Arthritis and Rheumatology Consultants, PA; USA), Melissa Harvey (Institute of Rheumatic and Autoimmune Diseases; USA), Maren Hilton (Arthritis and Rheumatology Consultants, PA; USA), Tiffany Hsu (Brigham and Women's Hospital; USA), Zara Izadi (University of California, San Francisco, CA; USA), Arundathi Jayatilleke (Temple University Hospital; USA), David Karp (UT Southwestern Medical Center; USA), Gilbert Kepecs (Private Practice; USA), Neil Kramer (Institute of Rheumatic and Autoimmune Diseases; USA), Concetta Lamore (Institute of Rheumatic and Autoimmune Diseases; USA), Nicholas Lebedoff (Arthritis and Rheumatology Consultants, PA; USA), Susan Leonard (Arthritis and Rheumatology Consultants, PA;USA), Sushama Mody (Riverside Medical Group; USA), Jennifer Morgan (Arthritis and Rheumatology Consultants, PA; USA), Emily Pfeifer (Arthritis and Rheumatology Consultants, PA; USA), Guillermo Quiceno (UT Southwestern Medical Center; USA), Robert Quinet (Ochsner Medical Center Rheumatology Department; USA), Elliot Rosenstein (Institute of Rheumatic and Autoimmune Diseases; USA), Eric Ruderman (Northwestern Memorial; USA), Evangeline Scopelitis (Ochsner Medical Center Rheumatology Department; USA), Naomi Serling-Boyd (Brigham and Women's Hospital; USA), Faizah Siddique (Loyola University Medical Center; USA), Archibald Skemp (Arthritis and Rheumatology Consultants, PA; USA), Derrick Todd (Brigham and Women's Hospital; USA), Karen T Toribio (Ochsner Medical Center Rheumatology Department; USA), Rachel Wallwork (Brigham and Women's Hospital; USA), Tameka Webb-Detiege (Ochsner Medical Center Rheumatology Department; USA), Douglas White (Gundersen Health System; USA), Jeffrey Wilson (Arthritis and Rheumatology Consultants, PA; USA), Melanie Winter (Gundersen Health System; USA), Leanna Wise (Los Angeles County + USC Medical Center; USA), Anne Wolff (Arthritis and Rheumatology Consultants, PA; USA), Kristen Young (UT Southwestern Medical Center; USA), Jerald Zakem (Ochsner Medical Center Rheumatology Department; USA), JoAnn Zell (University of Colorado; USA), Kurt Zimmerman (Arthritis and Rheumatology Consultants, PA; USA).
Contributors: AS, MS and PMM had access to the study data, developed the figures and tables, and vouch for the data and analyses. MS performed the statistical analyses and contributed to data quality control, data analysis and interpretation of the data. AS, MG, SL-T, JL, LL, CR, MJS, GS, CAS, SA-A, JB-C, LC, RC, LG, EH, RH, KLH, ZI, PK and LK-F, contributed to data collection, data quality control, data analysis and interpretation of the data. EFM, JS, ES, PS, LT, ZSW, SB, WC, RG, JH and LJ contributed to data collection, data analysis and interpretation of the data. PCR, JY and PMM, directed the work, designed the data collection methods, contributed to data collection, data analysis and interpretation of the data, and had final responsibility for the decision to submit for publication. All authors contributed intellectual content during the drafting and revision of the work and approved the final version to be published.
Funding: Financial support from the American College of Rheumatology (ACR) and European League Against Rheumatism (EULAR).
Disclaimer: The views expressed here are those of the authors and participating members of the COVID-19 Global Rheumatology Alliance and do not necessarily represent the views of the American College of Rheumatology (ACR), the European League Against Rheumatism (EULAR), the (UK) National Health Service (NHS), the National Institute for Health Research (NIHR), or the (UK) Department of Health, or any other organisation.
Competing interests: AS reports personal fees from lectures for AbbVie, MSD, Roche, BMS and Pfizer, all outside the submitted work. MG reports grants from National Institutes of Health, NIAMS, outside the submitted work. JL reports a research grant from Pfizer, outside of the submitted work. EFM reports that LPCDR received support for specific activities: grants from Abbvie, Novartis, Janssen-Cilag, Lilly Portugal, Sanofi, Grünenthal S.A., MSD, Celgene, Medac, Pharmakern and GAfPA; grants and non-financial support from Pfizer; non-financial support from Grünenthal GmbH, outside the submitted work. CR has received consulting/speaker’s fees from Abbvie, Amgen, AstraZeneca, BMS, Biogen, Eli Lilly, Glenmark, GSK, MSD, Mylan and Pfizer, and grants from Biogen, Lilly and Nordic Pharma, all unrelated to this manuscript. MJS is supported by unrestricted grants from AbbVie, Biogen, Gilead, Lilly, MSD, Novartis and Pfizer. Her work is supported by grants from the National Institutes of Health and Agency for Healthcare Research and Quality. She leads the Data Analytic Center for the American College of Rheumatology, which is unrelated to this work. ES reports non-financial support from Canadian Arthritis Patient Alliance, outside the submitted work. JS is supported by the National Institute of Arthritis and Musculoskeletal and Skin Diseases (grant numbers K23 AR069688, R03 AR075886, L30 AR066953, P30 AR070253 and P30 AR072577), the Rheumatology Research Foundation (R Bridge Award), the Brigham Research Institute, and the R. Bruce and Joan M. Mickey Research Scholar Fund. He has received research support from Amgen and Bristol-Myers Squibb and performed consultancy for Bristol-Myers Squibb, Gilead, Inova Diagnostics, Janssen, Optum and Pfizer unrelated to this work. PS reports personal fees from American College of Rheumatology/Wiley Publishing, outside the submitted work. TT reports personal fees for lectures and expertises from Amgen, Arrow, Biogen, BMS, Chugai, Expanscience, Gilead, Grunenthal, LCA, Lilly, Medac, MSD, Nordic, Novartis, Pfizer, Sandoz, Sanofi, Theramex, Thuasne, TEVA and UCB, and reports financial support or fees for research activities from Amgen, Bone Therapeutics, Chugai, MSD, Novartis, Pfizer and UCB, all unrelated to this manuscript. ZSW reports grant support from Bristol-Myers Squibb and consulting fees from Viela Bio. JB-C has received consulting/speaker’s fees from Abbvie, MSD, BMS and Roche, and grants from Pfizer, all unrelated to this manuscript. He reports non-branded marketing campaigns for Novartis. PC has received consulting and lecturing fees from Abbvie, AstraZeneca, Bristol-Myers Squibb, Gilead, Glaxo Smith Kline, Innotech, Janssen, Merck Sharp Dohme, Roche, Servier and Vifor. LC has not received fees or personal grants from any laboratory, but her institute works by contract for laboratories among other institutions, such as Abbvie Spain, Eisai, Gebro Pharma, Merck Sharp & Dohme España, S.A., Novartis Farmaceutica, Pfizer, Roche Farma, Sanofi Aventis, Astellas Pharma, Actelion Pharmaceuticals España, Grünenthal GmbH and UCB Pharma. LG reports personal consultant fees from AbbVie, Amgen, BMS, Biogen, Celgene, Gilead, Janssen, Lilly, Novartis, Pfizer, Samsung Bioepis, Sanofi-Aventis and UCB, and grants from Amgen, Lilly, Janssen, Pfizer, Sandoz, Sanofi and Galapagos, all unrelated to this manuscript. RG reports non-financial support from Pfizer Australia, personal fees from Pfizer Australia, personal fees from Cornerstones, personal fees from Janssen New Zealand, non-financial support from Janssen Australia, personal fees from Novartis, outside the submitted work. EH reports personal consultant fees from Actelion, Sanofi-Genzyme and GSK, and grants from GSK, all unrelated to this manuscript. RH reports research grant from Pfizer and personal fees from AbbVie, Pfizer, Novartis, Amgen, Mylan, Gilead, Medac and Takeda, all outside the submitted work. JH reports grants from Rheumatology Research Foundation, grants from Childhood Arthritis and Rheumatology Research Alliance (CARRA), personal fees from Novartis, outside the submitted work. KLH reports she has received non-personal speaker’s fees from Abbvie and grant income from BMS, UCB and Pfizer, all unrelated to this manuscript. KLH is supported by the NIHR Manchester Biomedical Research Centre. PCR reports personal fees from Abbvie, Eli Lilly, Gilead, Janssen, Novartis, Pfizer, Roche and UCB, non-financial support from BMS, research funding from Janssen, Novartis, Pfizer and UCB, all outside the submitted work. JY reports consulting fees from AstraZeneca and Eli Lilly, and grants from Pfizer, outside the submitted work. PMM has received consulting/speaker’s fees from Abbvie, BMS, Celgene, Eli Lilly, Janssen, MSD, Novartis, Orphazyme, Pfizer, Roche and UCB, all unrelated to this manuscript, and is supported by the National Institute for Health Research (NIHR), University College London Hospitals (UCLH) and Biomedical Research Centre (BRC).
Provenance and peer review: Not commissioned; externally peer reviewed.
Supplemental material: This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise. | (1?10 MG/DAY AND }10 MG/DAY) | DrugDosageText | CC BY-NC | 33504483 | 19,861,421 | 2021-07 |
What was the outcome of reaction 'COVID-19'? | Factors associated with COVID-19-related death in people with rheumatic diseases: results from the COVID-19 Global Rheumatology Alliance physician-reported registry.
To determine factors associated with COVID-19-related death in people with rheumatic diseases.
Physician-reported registry of adults with rheumatic disease and confirmed or presumptive COVID-19 (from 24 March to 1 July 2020). The primary outcome was COVID-19-related death. Age, sex, smoking status, comorbidities, rheumatic disease diagnosis, disease activity and medications were included as covariates in multivariable logistic regression models. Analyses were further stratified according to rheumatic disease category.
Of 3729 patients (mean age 57 years, 68% female), 390 (10.5%) died. Independent factors associated with COVID-19-related death were age (66-75 years: OR 3.00, 95% CI 2.13 to 4.22; >75 years: 6.18, 4.47 to 8.53; both vs ≤65 years), male sex (1.46, 1.11 to 1.91), hypertension combined with cardiovascular disease (1.89, 1.31 to 2.73), chronic lung disease (1.68, 1.26 to 2.25) and prednisolone-equivalent dosage >10 mg/day (1.69, 1.18 to 2.41; vs no glucocorticoid intake). Moderate/high disease activity (vs remission/low disease activity) was associated with higher odds of death (1.87, 1.27 to 2.77). Rituximab (4.04, 2.32 to 7.03), sulfasalazine (3.60, 1.66 to 7.78), immunosuppressants (azathioprine, cyclophosphamide, ciclosporin, mycophenolate or tacrolimus: 2.22, 1.43 to 3.46) and not receiving any disease-modifying anti-rheumatic drug (DMARD) (2.11, 1.48 to 3.01) were associated with higher odds of death, compared with methotrexate monotherapy. Other synthetic/biological DMARDs were not associated with COVID-19-related death.
Among people with rheumatic disease, COVID-19-related death was associated with known general factors (older age, male sex and specific comorbidities) and disease-specific factors (disease activity and specific medications). The association with moderate/high disease activity highlights the importance of adequate disease control with DMARDs, preferably without increasing glucocorticoid dosages. Caution may be required with rituximab, sulfasalazine and some immunosuppressants.
Key messages
What is already known about this subject?
To date, most available data on outcomes for people with rheumatic diseases infected with SARS-CoV-2 come from single centre or single country case series or from one large international registry; the COVID-19 Global Rheumatology Alliance (GRA) physician registry.
The first GRA publication identified factors associated with higher odds of COVID-19 hospitalisation, including older age, presence of comorbidities and higher dosages of glucocorticoids (≥10 mg/day of prednisolone equivalent).
Clinical outcome information on patients with COVID-19 who have rheumatic disease therefore remains limited, particularly with regard to factors associated with COVID-19-related death.
What does this study add?
In this analysis of 3729 patients with rheumatic diseases, older age, male sex, and cardiovascular and chronic lung disease were associated with COVID-19-related death.
Disease-specific factors, namely, moderate/high disease activity and certain medications (rituximab, sulfasalazine and immunosuppressants (as opposed to immunomodulators like disease-modifying anti-rheumatic drugs (DMARDs)) were also associated with COVID-19-related death.
How might this impact on clinical practice or future developments?
There is differential risk of COVID-19-related death according to disease activity and treatments in patients with rheumatic disease, highlighting the need for adequate disease control with DMARDs, preferably without increasing the glucocorticoid dosage.
Key messages
What is already known about this subject?
To date, most available data on outcomes for people with rheumatic diseases infected with SARS-CoV-2 come from single centre or single country case series or from one large international registry; the COVID-19 Global Rheumatology Alliance (GRA) physician registry.
The first GRA publication identified factors associated with higher odds of COVID-19 hospitalisation, including older age, presence of comorbidities and higher dosages of glucocorticoids (≥10 mg/day of prednisolone equivalent).
Clinical outcome information on patients with COVID-19 who have rheumatic disease therefore remains limited, particularly with regard to factors associated with COVID-19-related death.
What does this study add?
In this analysis of 3729 patients with rheumatic diseases, older age, male sex, and cardiovascular and chronic lung disease were associated with COVID-19-related death.
Disease-specific factors, namely, moderate/high disease activity and certain medications (rituximab, sulfasalazine and immunosuppressants (as opposed to immunomodulators like disease-modifying anti-rheumatic drugs (DMARDs)) were also associated with COVID-19-related death.
How might this impact on clinical practice or future developments?
There is differential risk of COVID-19-related death according to disease activity and treatments in patients with rheumatic disease, highlighting the need for adequate disease control with DMARDs, preferably without increasing the glucocorticoid dosage.
Introduction
There is a lack of robust data to inform our understanding of outcomes following SARS-CoV-2 infection in patients with inflammatory rheumatic diseases, leading to uncertainties regarding chronic disease management, especially for those taking immunosuppressant or immunomodulatory drugs.1–3
Whether people with rheumatic diseases belong to a vulnerable, higher risk population for SARS-CoV-2 infection and have poorer outcomes is unclear.1–8 In general, this population seems to have similar or only slightly poorer outcomes compared with those without rheumatic disease.7–9 However, important confounding disease-related factors, such as disease activity or treatments, have previously not been addressed.
Medications commonly used to treat rheumatic diseases have been used or are being tested for the prevention and/or treatment of COVID-19 and its complications,10 raising questions about the impact of these treatments on the outcomes of SARS-CoV-2 infection. Continuation of immunomodulatory or immunosuppressive therapy is essential for controlling rheumatic disease activity, avoiding disease progression and preventing joint or organ-damage related to sustained inflammation. Withdrawal of effective treatments should be based on sound evidence, even during a pandemic.
To generate more granular data relevant to rheumatic diseases, a global network of rheumatologists, data scientists and patients developed a COVID-19 physician-reported case registry in March 2020.11 12 Analysis of the first 600 patients revealed that older age and comorbidities were associated with hospitalisation,13 similar to results in the general population.8 14 More robust data on the risk of poor outcomes, in particular risk of death, are required.
The aim of this study was to investigate factors associated with COVID-19-related death in patients with rheumatic diseases and to analyse these associations by disease group.
Methods
Data source
The COVID-19 Global Rheumatology Alliance (C19-GRA) physician-reported registry is an observational registry launched on 24 March 2020. Data are entered voluntarily by rheumatologists or under supervision of rheumatologists; patients are eligible for inclusion if they have a pre-existing rheumatic disease and a COVID-19 diagnosis. Data are entered either directly into the global or European data entry systems or transferred from national registries (France, Germany, Italy, Portugal and Sweden).
We used data collected on or before 1 July 2020. Further details of this registry have been described elsewhere.11–13 Countries were assigned to the six WHO regions (www.who.int); the ‘Americas’ was further divided into north and south. Given the registry collects anonymous data, the UK Health Research Authority and the University of California San Francisco Institutional Review Board considered it exempt from patient consent.
Patient stratification into diagnostic groups
Rheumatic diseases differ regarding the disease-modifying antirheumatic drugs (DMARDs) approved for their treatment. To minimise the impact of this heterogeneity on the associations of interest, in addition to the main analysis with all patients, diagnostic categories were defined (figure 1) and stratified analyses were undertaken for patients with (1) inflammatory joint diseases (IJD), (2) rheumatoid arthritis (a subset of the IJD subgroup) and (3) connective tissue diseases (CTD)/vasculitis.
Figure 1 Disease and medication groups. ANCA, anti-neutrophil cytoplasm antibodies; DMARD, disease-modifying antirheumatic drugs; IgG, immunoglobulin; IL, interleukin; JAK, Janus kinase; TNF, tumour necrosis factor.
COVID-19 reporting and outcome
Both confirmed and presumptive cases of COVID-19 were reported. The method of COVID-19 diagnosis was specified: PCR, CT scan, metagenomic testing, laboratory assays or based on symptoms only.
For analysis, patients were subsequently categorised into (1) confirmed or high likelihood of COVID-19 (chest imaging (CT or chest X-ray) showing bilateral infiltrates and/or symptoms after close contact with a known laboratory-confirmed COVID-19 positive patient) or (2) presumptive cases based on symptoms alone.
The primary outcome was COVID-19-related death.
Treatment prior to COVID-19
Antirheumatic medications used prior to COVID-19 diagnosis were categorised into groups shown in figure 1. Immunomodulatory drugs (conventional synthetic (cs)/biological (b)/targeted synthetic (ts) DMARDs) were distinguished from immunosuppressive drugs (azathioprine, cyclophosphamide, ciclosporin, mycophenolate mofetil/mycophenolic acid, tacrolimus) as recommended by Isaacs and Burmester15; glucocorticoids are also immunosuppressive but they were examined separately and categorised by prednisolone-equivalent dosage (1–10 mg/day and >10 mg/day). Methotrexate monotherapy was adopted as the medication reference group; methotrexate is the anchor drug in multiple rheumatic diseases16 and it represents the largest medication category in the registry.
Statistical analyses
Descriptive tables were produced for the whole cohort and then by diagnostic group, country (for the six countries with the highest number of cases: France, Germany, Italy, Spain, UK and USA) and medication. Independent associations between demographic and disease features and COVID-19-related death were estimated using multivariable logistic regression and reported as OR and 95% CI. Covariates included in the model were age, sex, key comorbidities (hypertension alone or cardiovascular disease (CVD) alone, hypertension combined with CVD, chronic lung disease, chronic kidney disease (CKD) and diabetes), smoking status (ever vs never), rheumatic disease diagnostic group, disease activity as per the physician’s global assessment (severe/high or moderate disease activity vs minimal/low disease activity or remission), rheumatic disease treatment prior to COVID-19 diagnosis and prednisolone-equivalent glucocorticoid use.
All patients with confirmed or presumptive COVID-19 were included in the main analyses. Patients with missing primary outcome (N=82) or missing values for age, sex and DMARD (N=19) were excluded from analysis. Missing values for comorbidities, smoking status, glucocorticoid therapy and disease activity were derived by multiple imputation using full conditional specification.17 Results of the logistic regression analyses for 10 imputed datasets were pooled by Rubin’s rules. As disease activity was missing for all French patients, country-level life expectancy was used in the imputation model to explain potential structural differences in disease activity between countries not accounted for in the patient-level data (data from 2018, source: http://hdr.undp.org/).
To account for pronounced heterogeneity between participating countries regarding both healthcare systems and infection dynamics, countries were implicitly considered as data clusters in the regression analysis by assuming that the data arose from a cluster sample design; this was done by applying a Taylor series linearisation in the variance estimation.18
For patients listed as having more than one rheumatic disease or being treated with more than one of the medications of interest, we created a hierarchy based on clinical expertise to categorise patients. This process creates disjoint categories, allowing a clear reference group for interpretation of the regression models and avoiding collinearities. Patients with more than one of the following diseases were grouped according to the following hierarchy: systemic lupus erythematosus (SLE)>vasculitis>other CTD>RA>psoriatic arthritis (PsA)>(other) spondyloarthritis (SpA)>other IJD>other non-IJD/non-CTD rheumatic disease. Patients receiving multiple csDMARDs or immunosuppressants (except glucocorticoids) were grouped according to the following hierarchy: immunosuppressants>sulfasalazine>antimalarials>leflunomide>methotrexate. Patients receiving a b/tsDMARD were considered solely in the b/tsDMARD group. Patients treated with more than one b/tsDMARD (N=4), patients receiving IL-1 inhibitors (N=20) and patients receiving DMARDs atypical for their disease subgroup (N=48) were excluded from analysis due to very low numbers (figure 2). Patients were excluded from a particular analysis if the medication they received provided ≤20 patients for that analysis or if there were no deaths reported for that specific medication.
Figure 2 Patient flowchart. Some patients had diagnoses in multiple groups; as a result, the sum of patients in each group is greater than the total number of patients. (*) Patients belonging to more than one diagnosic group: IJD and CTD: N=78 (10 deaths); IJD and other: N=70 (12 deaths); CTD and other: N=50 (13 deaths); IJD and CTD and other: N=5 (2 deaths). (§) Patients belonging to more than one diagnosic group: IJD and CTD: N=77 (10 deaths); IJD and other: N=70 (12 deaths); CTD and other: N=49 (12 deaths); IJD and CTD and other: N=5 (2 deaths). (#) Patients belonging to more than one diagnosic group: IJD and CTD: N=59 (7 deaths). (**) Non-typical DMARDs for IJD and RA: immunosuppressants and belimumab; non-typical DMARDs for RA: IL-17/IL-23/IL-12+23 inhibitors. (***) Non-typical DMARDs for CTD: abatacept, IL-17/IL-23/IL-12+23 inhibitors, sulfasalazine, leflunomide and tsDMARDs. b/tsDMARDs, biological/targeted synthetic disease-modifying antirheumatic drugs; CTD, connective tissue disease/vasculitis; DMARDs, disease-modifying anti-rheumatic drugs; IJD, inflammatory joint disease; IL, interleukin; RA, rheumatoid arthritis.
The following sensitivity analyses were performed to examine the robustness of our findings to procedures for handling missing data: (1) excluding patients from France (no disease activity data available); (2) complete case analysis. Further sensitivity analyses were conducted to assess the stability of the results: (1) limited to patients with confirmed or highly likely COVID-19; (2) using the alternative outcome ‘death or invasive ventilation’; (3) using a reduced number of covariates to assess the risk of overfitting; (4) analysis explicitly controlling for country, using data from the top six reporting countries; (5) analysis stratified for several binary key variables (age >65 or not, sex, ever smoked vs not, high/moderate/severe disease activity vs remission/low disease activity, CVD, chronic lung disease, glucocorticoid use) to assess the possibility of interactions.
Data were considered statistically significant for p values <0.05. All analyses were conducted in SAS (V.9.4) and R (V.3.6.3).
Results
As of 1 July 2020, 3830 patients were in the registry, of whom 3729 had no missing values for death, age, sex and DMARD therapy (table 1, results for all patients; online supplemental table 1, results stratified by diagnostic subgroup; online supplemental table 2, results stratified by country; online supplemental table 3, results stratified by medication of interest).
10.1136/annrheumdis-2020-219498.supp1 Supplementary data
Table 1 Patient demographic and clinical characteristics
Parameter Not deceased Deceased Total
N 3339 390 3729
General
Age (years) 55.5 (15.2) 69.7 (14.6) 57.0 (15.7)
≤30 197 (5.9) 9 (2.3) 206 (5.5)
31–50 1012 (30.3) 31 (7.9) 1043 (28)
51–65 1255 (37.6) 82 (21) 1337 (35.9)
66–75 536 (16.1) 109 (27.9) 645 (17.3)
>75 339 (10.2) 159 (40.8) 498 (13.4)
Male sex 1031 (30.9) 164 (42.1) 1195 (32)
Ever smoker 664 (23.3)
(N=2854)
(Missing=485) 112 (36.1)
(N=310)
(Missing=80) 776 (24.5)
(N=3164)
(Missing=565)
Regions
African region 14 (0.4) 2 (0.5) 16 (0.4)
Eastern Mediterranean region 83 (2.5) 11 (2.8) 94 (2.5)
European region 2040 (61.1) 275 (70.5) 2315 (62.1)
North American region 1024 (30.7) 81 (20.8) 1105 (29.6)
South American region 112 (3.4) 10 (2.6) 122 (3.3)
South-East Asian region 11 (0.3) 0 11 (0.3)
Western Pacific region 55 (1.6) 11 (2.8) 66 (1.8)
Inflammatory joint diseases
Rheumatoid arthritis 1224 (36.7) 170 (43.6) 1394 (37.4)
Spondyloarthritis 416 (12.5) 15 (3.8) 431 (11.6)
Psoriatic arthritis 420 (12.6) 20 (5.1) 440 (11.8)
Juvenile idiopathic arthritis (poly, oligo, not systemic) 21 (0.6) 4 (1) 25 (0.7)
Other inflammatory arthritis 90 (2.7) 8 (2.1) 98 (2.6)
Total Inflammatory joint diseases 2158 (64.6) 215 (55.1) 2373 (63.6)
Connective tissue diseases/Vasculitis
Systemic lupus erythematosus 355 (10.6) 36 (9.2) 391 (10.5)
Connective tissue diseases (other than SLE) 473 (14.2) 60 (15.4) 533 (14.3)
Vasculitis 258 (7.7) 68 (17.4) 326 (8.7)
Total CTD 1035 (31) 158 (40.5) 1193 (32.0)
Other RMDs
Total 306 (9.2) 50 (12.8) 356 (9.5)
Disease activity N=2464
(Missing=875) N=294
(Missing=96) N=2758
(Missing=971)
Remission 799 (32.4) 94 (32) 893 (32.4)
Minimal/low disease activity 1202 (48.8) 107 (36.4) 1309 (47.5)
Moderate disease activity 388 (15.7) 60 (20.4) 448 (16.2)
Severe/high disease activity 75 (3) 33 (11.2) 108 (3.9)
Other outcomes
Hospitalised 1368 (43.3)
(N=3162)
(Missing=177) 371 (96.6)
(N=384)
(Missing=6) 1739 (49)
(N=3546)
(Missing=183)
Invasive ventilation 67 (2.5)
(N=2701)
(Missing=638) 120 (40.8)
(N=294)
(Missing=96) 187 (6.2)
(N=2995)
(Missing=734)
Comorbidities N=3314
(Missing=25) N=386
(Missing=4) N=3700
(Missing=29)
Hypertension 1095 (33) 212 (54.9) 1307 (35.3)
Cardiovascular disease 318 (9.6) 124 (32.1) 442 (11.9)
Cerebrovascular disease 89 (2.7) 20 (5.2) 109 (2.9)
Chronic lung disease 581 (17.5) 138 (35.8) 719 (19.4)
Chronic kidney disease 181 (5.5) 77 (19.9) 258 (7)
Obesity (BMI ≥30) 539 (16.3) 58 (15) 597 (16.1)
Morbid obesity (BMI ≥40) 106 (3.2) 16 (4.1) 122 (3.3)
Diabetes 410 (12.4) 95 (24.6) 505 (13.6)
Cancer 165 (5) 49 (12.7) 214 (5.8)
Other comorbidities 771 (23.3) 126 (32.6) 897 (24.2)
Number of comorbities 1.3 (1.3) 2.5 (1.6) 1.4 (1.3)
No comorbidity 1090 (32.9) 28 (7.3) 1118 (30.2)
One comorbidity 1032 (31.1) 83 (21.5) 1115 (30.1)
Two comorbidities 597 (18) 110 (28.5) 707 (19.1)
≥3 comorbidites 595 (18) 165 (42.7) 760 (20.5)
DMARD therapies
csDMARDs monotherapy 592 (17.7) 59 (15.1) 651 (17.5)
csDMARDs combination therapy 692 (20.7) 61 (15.6) 753 (20.2)
Methotrexate monotherapy 531 (15.9) 47 (12.1) 578 (15.5)
Methotrexate combination therapy 607 (18.2) 52 (13.3) 659 (17.7)
Leflunomide monotherapy 61 (1.8) 12 (3.1) 73 (2)
Leflunomide combination therapy 120 (3.6) 10 (2.6) 130 (3.5)
Sulfasalazine monotherapy 51 (1.5) 16 (4.1) 67 (1.8)
Sulfasalazine combination therapy 129 (3.9) 26 (6.7) 155 (4.2)
Antimalarial monotherapy 287 (8.6) 17 (4.4) 304 (8.2)
Antimalarial combination therapy 322 (9.6) 39 (10) 361 (9.7)
Immunosuppressants monotherapy 149 (4.5) 26 (6.7) 175 (4.7)
Immunosuppressants combination therapy 147 (4.4) 21 (5.4) 168 (4.5)
Mycophenolate mofetil monotherapy 68 (2) 14 (3.6) 82 (2.2)
Mycophenolate mofetil combination therapy 81 (2.4) 15 (3.8) 96 (2.6)
Azathioprine monotherapy 63 (1.9) 7 (1.8) 70 (1.9)
Azathioprine combination therapy 51 (1.5) 3 (0.8) 54 (1.4)
Cyclophosphamide monotherapy 10 (0.3) 3 (0.8) 13 (0.3)
Cyclophosphamide combination therapy 5 (0.1) 5 (1.3) 10 (0.3)
Tacrolimus monotherapy 5 (0.1) 2 (0.5) 7 (0.2)
Tacrolimus combination therapy 11 (0.3) 0 11 (0.3)
Ciclosporin monotherapy 3 (0.1) 0 3 (0.1)
Ciclosporin combination therapy 11 (0.3) 1 (0.3) 12 (0.3)
bDMARDs monotherapy 675 (20.2) 48 (12.3) 723 (19.4)
bDMARDs combination therapy 562 (16.8) 46 (11.8) 608 (16.3)
TNF inhibitors monotherapy 434 (13) 13 (3.3) 447 (12)
TNF inhibitors combination therapy 340 (10.2) 17 (4.4) 357 (9.6)
Abatacept monotherapy 28 (0.8) 4 (1) 32 (0.9)
Abatacept combination therapy 46 (1.4) 5 (1.3) 51 (1.4)
B-cell-targeted bDMARDs monotherapy 71 (2.1) 25 (6.4) 96 (2.6)
B-cell-targeted bDMARDs combination therapy 106 (3.2) 18 (4.6) 124 (3.3)
Rituximab monotherapy 66 (2) 25 (6.4) 91 (2.4)
Rituximab combination therapy 85 (2.5) 17 (4.4) 102 (2.7)
Belimumab monotherapy 5 (0.1) 0 5 (0.1)
Belimumab combination therapy 22 (0.7) 1 (0.3) 23 (0.6)
IL-6 inhibitors monotherapy 51 (1.5) 3 (0.8) 54 (1.4)
IL-6 inhibitors combination therapy 34 (1) 2 (0.5) 36 (1)
IL-1 inhibitors monotherapy 10 (0.3) 2 (0.5) 12 (0.3)
IL-1 inhibitors combination therapy 4 (0.1) 4 (1) 8 (0.2)
IL-17, IL-23, IL-12/23 inhibitors monotherapy 79 (2.4) 1 (0.3) 80 (2.1)
IL-17, IL-23, IL-12/23 inhibitors combination therapy 36 (1.1) 0 36 (1)
tsDMARDs monotherapy 61 (1.8) 5 (1.3) 66 (1.8)
tsDMARDs (*) combination therapy 71 (2.1) 10 (2.6) 81 (2.2)
JAK inhibitors monotherapy 54 (1.6) 4 (1) 58 (1.6)
JAK inhibitors combination therapy 67 (2) 9 (2.3) 76 (2)
Apremilast monotherapy 7 (0.2) 1 (0.3) 8 (0.2)
Apremilast combination therapy 3 (0.1) 1 (0.3) 4 (0.1)
No DMARD therapies 615 (18.4) 124 (31.8) 739 (19.8)
Further therapies
Glucocorticoids (#) 1056 (32)
(N=3302)
(Missing=37) 217 (57.1)
(N=380)
(Missing=10) 1273 (34.6)
(N=3682)
(Missing=47)
Glucocorticoids 1–10 mg/day 833 (25.6)
(N=3254)
(Missing=85) 150 (41.3)
(N=363)
(Missing=27) 983 (27.2)
(N=3617)
(Missing=112)
Glucocorticoids>10 mg/day 171 (5.3)
(N=3254)
(Missing=85) 49 (13.5)
(N=363)
(Missing=27) 220 (6.1)
(N=3617)
(Missing=112)
NSAIDs 600 (19.3)
(N=3103)
(Missing=236) 38 (11.0)
(N=345)
(Missing=45) 638 (18.5)
(N=3448)
(Missing=281)
Data are N (column %) for categorical variables or mean (SD) for continuous variables. The table includes all patients with a non-missing outcome and non-missing values for age, sex and disease-modifying anti-rheumatic drugs (DMARDs) (101 patients excluded). Data refer to patients with non-missing values for the respective variable; total N for patients with non-missing values is given in parentheses for variables with missing values; the total number of missing values is also given in parenthesis, for the applicable variables. (*) Includes one patient on a study medication (Lenabasum). (#) Includes patients with a missing glucocorticoid dosage.
bDMARD, biological disease-modifying antirheumatic drug; BMI, body mass index; csDMARD, conventional synthetic disease-modifying antirheumatic drug; CTD, connective tissue diseases; DMARD, disease-modifying antirheumatic drug; IL, interleukin; JAK, Janus kinase; JIA, juvenile idiopathic arthritis; N, number; NSAID, non-steroidal anti-inflammatory drugs; SLE, systemic lupus erythematosus; TNF, tumour necrosis factor; tsDMARD, targeted synthetic disease-modifying antirheumatic drug.
Patient characteristics and outcomes of COVID-19
Mean age was 57 (15.7) years and most patients were ≤65 years (2586/3729, 69.3%) and female (2534/3729, 68%). The most common disease was RA (1394/3729, 37.4%), followed by CTDs other than SLE (533/3729, 14.3%), SLE (391/3729, 10.5%), PsA (440/3729, 11.8%) and other SpA (431/3729, 11.6%).
Patients were primarily from Europe (2315/3729, 62.1%) or North America (1105/3729, 29.6%). Nearly half (1309/2758, 47.5%) had minimal or low disease activity and one-third (893/2758, 32.4%) were in remission before COVID-19. One-quarter of all patients (776/3164, 24.5%) were ever smokers.
Most patients had a laboratory-confirmed diagnosis of COVID-19 (2897/3729, 77.7%); 2.4% (91/3729) had a high likelihood of infection based on imaging or confirmed COVID-19 contacts.
Death occurred in 10.5% (390/3729) of patients; 68.7% (268/390) of those who died were >65 years. Nearly half of all patients (1739/3546; 49.0%) were hospitalised. Invasive ventilation was reported in 6.2% (187/2995) of patients, but in 40.8% (120/294) of those who died.
Comorbidities
Most patients (2582/3700, 69.8%) had at least one comorbidity, and 20.5% (760/3700) had more than three. The most frequent were hypertension (1307/3700, 35.3%), chronic lung disease (719/3700, 19.4%), obesity (BMI ≥30; 597/3700, 16.1%), diabetes (505/3700, 13.6%), other CVD (442/3700, 11.9%) and CKD (258/3700, 7.0%). Among deceased patients, the proportion of those with comorbidities was higher, with 42.7% (165/386) having ≥3 comorbidities, namely, 54.9% (212/386) with hypertension, 35.8% (138/386) with chronic lung disease, 24.6% (95/386) with diabetes, 32.1% (124/386) with other CVD and 19.9% (77/386) with CKD.
Treatments
At the time of COVID-19 diagnosis, 40.6% (1514/3729) of patients were treated only with csDMARDs, immunosuppressants or combinations of these; 35.7% (1331/3729) received bDMARDs and 3.9% (147/3729) received tsDMARDs. One-fifth (739/3729, 19.8%) were not receiving any DMARD/immunosuppressive treatment (except glucocorticoids), and this proportion was higher among deceased patients (124/390, 31.8%).
Among the patients not receiving any DMARD/immunosuppressive treatment, 39.8% (290/729) received glucocorticoids, 9.8% (70/712) with a prednisolone-equivalent dosage of >10 mg/day; the most frequent diagnostic categories being other non-specified rheumatic diseases (173/739, 23.4%), vasculitis (161/739, 21.8%), CTD other than SLE (156/739, 21.1%) and RA (110/739, 14.9%).
Country-specific differences
The majority of cases (2993/3729, 80.3%) were reported from six countries with considerable differences in reported percentages of death (online supplemental table 2). Overall, 10.5% (390/3729) of patients died, with highest proportions in the UK (91/435, 20.9%) and Italy (53/315, 16.8%). Death was reported in lower proportions in the USA (70/1005, 7.0%), Germany (15/198, 7.6%), France (62/793, 7.8%) and Spain (21/247, 8.5%). Other major differences between the countries were the distribution of rheumatic diseases and the distribution and frequency of comorbidities.
Factors associated with death
In multivariable analyses (table 2, figure 3), patients between 66 and 75 years of age were more likely to have died (OR 3.00, 95% CI 2.13 to 4.22) than those ≤65 years. The association was even more pronounced in patients over 75 years (6.18, 4.47 to 8.53; vs ≤65 years). Male sex was also associated with higher odds of death (1.46, 1.11 to 1.91). Current or former smoking was only associated with death in the RA subgroup (1.45, 1.02 to 2.04).
Figure 3 Results of the main logistic regression analysis. Shown are multivariable-adjusted ORs for the outcome COVID-19-related death with 95% CIs, assessing the association with (A) general patient characteristics, (B) comorbidities, (C) rheumatic disease diagnoses (RMD) and (D) rheumatic disease medications. ORs are shown for four groups: all patients (black), patients with inflammatory joint disease (red), patients with rheumatoid arthritis (orange), and patients with a connective tissue disease or vasculitis (blue). For (C), only ORs for all patients are shown. The reference categories are as follows: (A) ≤65 years, females, never smoked, remission or low disease activity; (B) the non-presence of the specific comorbidities (for all effects); (C) rheumatoid arthritis (for all effects); (D) methotrexate monotherapy (for all effects except for glucocorticoids), no glucocorticoids (for glucocorticoid dosage groups). Patients receiving multiple csDMARDs or immunosuppressants (except glucocorticoids) were grouped according to the following hierarchy: immunosuppressants>sulfasalazine>antimalarials>leflunomide>methotrexate; patients receiving a b/tsDMARD were considered solely in the b/tsDMARD group; glucocorticoids were examined separately and categorised by prednisolone-equivalent dosage (1–10 mg/day and >10 mg/day). bDMARD, biological disease-modifying anti-rheumatic drug; csDMARD, conventional synthetic disease-modifying antirheumatic drug; CTD, connective tissue diseases; CVD, cardiovascular disease; JIA, juvenile idiopathic arthritis; tsDMARD, targeted synthetic disease-modifying anti-rheumatic drug.
Table 2 Multivariable logistic regression analysis of factors associated with COVID-19-related death in patients with rheumatic diseases (all patients)
N deaths/patients (%) All Patients with inflammatory joint diseases (IJDs) Only patients with rheumatoid arthritis Patients with connective tissue diseases (CTDs) or vasculitis
384/3705 (10.4%) 211/2348 (9.0%) 166/1371 (12.1%) 147/1157 (12.7%)
N deaths/patients OR 95% CI N deaths/patients OR 95% CI N deaths/patients OR 95% CI N deaths/patients OR 95% CI
Age, years
Age≤65 118/2565 1 Reference 55/1657 1 Reference 40/840 1 Reference 56/779 1 Reference
65 years<Age≤75 109/644 3 2.13 to 4.22 71/426 3.63 2.55 to 5.15 55/314 3.10 1.68 to 5.72 33/187 2.29 1.34 to 3.93
Age>75 157/496 6.18 4.47 to 8.53 85/265 8.21 5.54 to 12.18 71/217 7.30 4.42 to 12.06 58/191 4.08 2.27 to 7.36
Male sex (vs female) 161/1188 1.46 1.11 to 1.91 82/788 1.31 0.95 to 1.8 55/345 1.17 0.78 to 1.76 63/296 1.66 0.96 to 2.86
Ever smoked (vs never) 140/922 1.21 0.94 to 1.57 84/607 1.26 0.93 to 1.72 71/385 1.45 1.02 to 2.04 42/248 1.11 0.67 to 1.86
Comorbidities
Hypertension alone or CVD alone 155/1150 1.19 0.89 to 1.59 79/690 1.04 0.74 to 1.46 66/454 1.11 0.74 to 1.67 69/406 1.56 1.06 to 2.29
Hypertension and CVD 89/301 1.89 1.31 to 2.73 53/168 2.29 1.25 to 4.23 38/118 2.03 1.03 to 3.97 28/106 1.57 0.78 to 3.16
Chronic lung disease 136/721 1.68 1.26 to 2.25 76/406 1.52 1.04 to 2.21 63/293 1.44 0.99 to 2.09 54/285 2.05 1.47 to 2.85
Chronic kidney disease 76/259 1.67 0.99 to 2.8 27/111 1.09 0.54 to 2.21 21/83 1.01 0.46 to 2.24 41/124 2.30 1.37 to 3.88
Diabetes mellitus 96/508 1.38 0.88 to 2.17 55/313 1.31 0.95 to 1.79 39/213 1.08 0.72 to 1.61 32/154 1.39 0.64 to 3
Rheumatic disease
Rheumatoid arthritis 160/1326 1 Reference 166/1373 1 Reference n.a. n.a.
Systemic lupus erythematosus 36/391 1.2 0.70 to 2.04 n.a. n.a. 32/378 1 Reference
Vasculitis 67/325 0.8 0.60 to 1.08 n.a. n.a. 64/318 0.81 0.49 to 1.33
Other connective tissue diseases 53/473 0.75 0.58 to 0.97 n.a. n.a. 51/461 0.78 0.39 to 1.54
Psoriasis arthritis 19/429 0.75 0.53 to 1.07 19/437 0.82 0.55 to 1.22 n.a. n.a.
Spondyloarthritis 15/423 0.72 0.34 to 1.54 15/424 0.82 0.4 to 1.69 n.a. n.a.
Other inflammatory arthritis or non-systemic JIA 10/109 0.79 0.46 to 1.34 11/114 0.76 0.43 to 1.36 n.a. n.a.
Other rheumatic diseases (not IJDs/CTDs/vasculitis) 24/229 0.51 0.35 to 0.73 n.a. n.a. n.a.
High/moderate/severe disease activity (DA) vs remission/low DA 109/722 1.87 1.27 to 2.77 54/453 1.6 1.13 to 2.26 44/274 1.60 1.03 to 2.47 51/230 2.45 1.49 to 4.02
Medication
Methotrexate 47/595 1 Reference 41/487 1 Reference 34/354 1 Reference 6/94 1 Reference
No DMARD therapy 124/739 2.11 1.48 to 3.01 38/239 2.08 1.38 to 3.14 25/110 2.12 1.34 to 3.37 67/353 3.18 1.61 to 6.27
Leflunomide 12/90 1.56 0.9 to 2.7 10/83 1.37 0.69 to 2.73 9/68 1.43 0.71 to 2.86 n.a.
Antimalarials 27/426 0.99 0.66 to 1.48 17/167 1.14 0.65 to 2 17/141 1.24 0.7 to 2.19 11/271 1.38 0.48 to 4.02
Sulfasalazine 33/144 3.6 1.66 to 7.78 31/137 3.40 1.46 to 7.93 21/85 2.62 1.21 to 5.68 n.a.
Immunosuppressants 38/276 2.22 1.43 to 3.46 n.a. n.a. 32/247 2.44 1.06 to 5.65
TNF inhibitors 30/803 0.85 0.52 to 1.36 26/764 0.77 0.42 to 1.41 16/292 0.82 0.39 to 1.76 4/39 2.00 0.36 to 11.2
Abatacept 9/81 1.20 0.61 to 2.34 9/75 1.3 0.62 to 2.71 9/68 1.4 0.65 to 2.99 n.a.
Rituximab 42/192 4.04 2.32 to 7.03 22/90 5.42 2.77 to 10.61 21/86 4.99 2.43 to 10.26 22/104 3.72 1.21 to 11.48
Belimumab 1/27 0.71 0.19 to 2.68 n.a. n.a. 1/27 1.07 0.21 to 5.37
IL-6 inhibitors 5/90 0.83 0.38 to 1.84 1/68 0.25 0.03 to 2.43 1/63 0.25 0.03 to 2.33 4/23 2.69 0.88 to 8.19
IL-17/IL-23/IL-12+23 inhibitors 1/115 0.25 0.03 to 2.04 1/112 0.26 0.03 to 2.06 n.a. n.a.
tsDMARDs 15/145 1.60 0.91 to 2.8 15/142 1.75 0.99 to 3.12 13/118 1.57 0.75 to 3.27 n.a.
Glucocorticoids (GCs)
No GCs 165/2417 1 Reference 109/1721 1 Reference 78/863 1 Reference 38/551 1 Reference
GCs 1–10 mg/day 170/1062 1.43 0.98 to 2.09 89/567 1.36 0.76 to 2.45 78/464 1.34 0.66 to 2.74 75/469 1.69 1.11 to 2.57
GCs>10 mg/day 49/226 1.69 1.18 to 2.41 12/60 1.55 0.67 to 3.57 10/44 1.59 0.6 to 4.18 34/137 1.93 1.11 to 3.36
Missing values were imputed via multiple imputation, patient numbers may thus be rounded. Effects significant at level α=0.05 are marked in bold. Patients were excluded from a particular analysis if the medication they received provided ≤20 patients for that analysis or if there were no deaths reported for that specific medication.
TNF; tumour necrosis factor; CTD, connective tissue diseases; CVD, cardiovascular duisease; DMARD, disease-modifying antirheumatic drugs; GC, glucocorticoids; IL, interleukin; JIA, juvenile idiopathic arthritis; N, number; n.a., not applicable; tsDMARD, targeted synthetic disease-modifying antirheumatic drugs.
Other factors associated with death included chronic lung disease (1.68, 1.26 to 2.25) and CVD combined with hypertension (1.89, 1.31 to 2.73), whereas hypertension or CVD alone did not show a significant association. CKD was significantly associated with death in patients with CTD or vasculitis (2.30, 1.37 to 3.88) but not in other disease subgroups.
Across all diagnostic groups, treatments with leflunomide, antimalarials, TNF inhibitors, abatacept, belimumab, IL-6 inhibitors, IL-17/IL-23/IL-12+23 inhibitors and tsDMARDs were not associated with death, as compared with methotrexate monotherapy. In the overall model, not receiving DMARD treatment was associated with death (2.11, 1.48 to 3.01) compared with methotrexate monotherapy. This was also seen in the IJD, RA and CTD subgroups.
Compared with methotrexate monotherapy, treatments associated with a higher odds of death were rituximab (4.04, 2.32 to 7.03, in the overall model; 5.42, 2.77 to 10.61, in the IJD subgroup; 4.99, 2.43 to 10.26, in the RA subgroup; 3.72, 1.21 to 11.48, in the CTD/vasculitis subgroup), sulfasalazine (3.60, 1.66 to 7.78, in the overall model and consistent across all subgroups) and immunosuppressants (azathioprine, cyclophosphamide, ciclosporin, mycophenolate or tacrolimus: 2.22, 1.43 to 3.46, in the overall model; 2.44, 1.06 to 5.65, in the CTD/vasculitis subgroup; not applicable to other subgroups).
An additional analysis indicated that the association of sulfasalazine with an increased odds for death was mainly driven by the larger group of sulfasalazine monotherapy and persisted even when sulfasalazine combination treatment (plus either antimalarials, leflunomide or methotrexate) was considered separately (data not shown).
Treatment with higher dosages of glucocorticoids (>10 mg/day prednisolone-equivalent dose vs no use) was also found to be associated with death (1.69, 1.18 to 2.41), particularly in the CTD/vasculitis subgroup (1.93, 1.11 to 3.36).
Higher disease activity at COVID-19 diagnosis was consistently associated with death across all disease groups. Patients with high/moderate/severe disease activity had higher odds of death (1.87, 1.27 to 2.77) than patients with low disease activity or in remission (overall model and consistent across all subgroups).
Sensitivity analyses
Results were largely consistent in our sensitivity analyses (online supplemental tables 4–9). In the complete case analysis (online supplemental table 5), the association between sulfasalazine and death was no longer statistically significant. In stratified analyses (online supplemental tables 10–16), sulfasalazine use was not associated with death among patients that never smoked, with the OR among ever smokers being almost threefold than among non-smokers (online supplemental table 12).
Discussion
With global cooperation, the C19-GRA physician-reported registry is the largest collection to date of patients with rheumatic diseases and COVID-19. We found that moderate/high disease activity was significantly associated with COVID-19-related death, confirming recent recommendations regarding the importance of disease control in rheumatic diseases in the COVID-19 era.1 Other factors associated with death were older age, male sex and the presence of comorbidities, which is consistent with reports from the general population.8 Overall, compared with methotrexate monotherapy, most DMARDs were not associated with higher odds of death, although rituximab and sulfasalazine were notable exceptions. Prednisolone-equivalent dosages >10 mg/day and other immunosuppressive drugs (as opposed to immunomodulatory DMARDs) were also associated with COVID-19-related death.
In this cohort of patients with underlying rheumatic diseases, the COVID-19-related death rate was 10.5%, clearly higher than that reported in the general population in most countries. However, this study was not designed to calculate a precise point estimate for mortality. Reporting biases and population-related factors, including COVID-19 testing rates, could explain this figure and, importantly, it should not be taken as an estimate of the overall death rate among patients with rheumatic diseases and COVID-19.
The association of rituximab with poorer COVID-19-related outcomes is a previously unreported finding outside of case reports. Rituximab binds to CD20 on the surface of B-cells, effectively depleting this cell type, and interferes with antibody development. Therefore, B-cell depletion could potentially compromise antiviral immunity, including the development of SARS-CoV-2 antibodies.19 With our data, it was not possible to determine the exact timing of infection following rituximab infusion, although all patients were clinically judged by their rheumatologist to have been exposed to the immunological effects of the drug at the time of COVID-19 diagnosis. The association between rituximab and COVID-19-related death could have also been influenced by the typical coadministration of methylprednisolone with rituximab.
A finding that merits further research is the higher odds of death found with sulfasalazine treatment. This association has also been reported in results from an international registry of patients with inflammatory bowel disease and COVID-19, where sulfasalazine or 5-aminosalicylate (5-ASA) use was associated with severe COVID-19 (adjusted OR of 3.1 (1.3 to 7.7)).20 This finding is surprising as sulfasalazine is usually considered to have a low immunosuppressive effect. Prior research supports an immune regulatory effect driven by sulfasalazine or its metabolite 5-ASA against other RNA viruses.21–24 However, causal interpretation of the association between sulfasalazine and COVID-19-related death should not be made. The perceived low immunosuppressive effect of sulfasalazine may have led rheumatologists to prescribe preferentially sulfasalazine over methotrexate in patients who were perceived to be at higher risk, for example, patients with pulmonary disease, smoking or recurrent chest infections. In an observational study like ours, this could lead to unmeasured confounding. A salient difference in sulfasalazine users in our study was a higher proportion of current or former smokers, compared with non-users. In the stratified analyses for chronic lung disease, the association between death and sulfasalazine was significant in both subgroups with and without chronic lung disease, while in the stratified analyses for smoking, the association between death and sulfasalazine was limited to ever smokers, so the factor ‘smoking’ could potentially be an effect modifier. Another potential explanation for this finding could be the merging of sulfasalazine combination therapy (with other csDMARDs) with sulfasalazine monotherapy; however, the increased odds for death persisted in the sulfasalazine monotherapy group and was not driven by the combination treatment (data not shown).
Despite the large overall sample size, for some therapies (eg, IL-6 and IL-17/IL-23/IL-12+23 inhibitors) the number of users was low and no firm conclusions could be made. IL-6 inhibitors have been used to counteract the hyperinflammatory state produced by COVID-19, with mostly disappointing randomised trial results.25 26 Their efficacy is still being investigated in ongoing trials, but it is reassuring that they were not associated with COVID-19-related death in our analyses. Previous studies had shown an association between TNF inhibitors and a decreased risk of sepsis and mortality in patients with RA after serious infection compared with csDMARDs.27 28 We could not confirm such an association after stratification by disease and adjustment for disease activity. However, the data indicate that some associations may exist among patients diagnosed with IJD other than RA (a subgroup comprising predominantly patients with axial SpA and PsA), in whom male sex and diabetes mellitus were associated with a higher odds of death, and TNF inhibitor use was associated with a lower odds of death (univariable analysis, data not shown). Due to a small number of deceased patients in this subgroup with non-RA subtypes of IJD (n=37 deaths), these effects could not be assessed in a multivariable model and this should be investigated in the future when higher case numbers allow a more stable assessment.
This study has limitations. As a cross-sectional, case-reporting registry, it may be subject to selection bias if more severe cases are more likely to come to the rheumatologists’ attention and therefore to be reported. There is an absence of a population-based comparator, and we are unable to make comparisons between those with and without COVID-19. Moreover, we caution against interpreting our estimates causally. There is likely unmeasured confounding dependent on the particularities of health systems and case reporting differences. We tried to address this by limiting the research questions to those that could be answered with this dataset and by accounting for potential confounders in our analyses. The high number of variables compared with outcome events in the subgroup models may result in biased estimates.29 30 However, the consistency between the main model and the sensitivity analyses (including using a lower number of variables) do not indicate an issue with overfitting.
In conclusion, people with rheumatic diseases with higher disease activity have higher odds of COVID-19-related death, highlighting the importance of disease control, preferably by managing DMARDs effectively without increasing glucocorticoids. Future studies should address the observed association of rituximab and sulfasalazine with poor outcomes. Finally, as in the general population, older age, male sex and/or the presence of comorbidities increase the odds of COVID-19-related death.
We wish to thank all rheumatology providers who entered data into the registry.
Data availability statement
Data are available upon reasonable request. Applications to access the data should be made to the C19-GRA Steering Committee.
Ethics statements
Patient consent for publication
Not required.
Ethics approval
The C19-GRA physician-reported registry was determined “not human subjects’ research” by the UK Health Research Authority and the University of Manchester, as well as under United States Federal Guidelines assessed by the University of California San Francisco Institutional Review Board.
Handling editor: Josef S Smolen
Twitter: @rheum_cat, @rthritis, @emilysirotich, @zach_wallace_md, @carmona_loreto, @hausmannmd, @philipcrobinson, @pedrommcmachado
AS and MS contributed equally.
PCR, JY and PMM contributed equally.
Correction notice: This article has been corrected since it published Online First. The collaborator names have been updated.
Collaborators: COVID-19 Global Rheumatology Alliance Consortium: Brahim Dahou (Association Rhumatologues Algériens Privés; Algeria), Marcelo Pinheiro (Universidade Federal De São Paulo Escola Paulista de Medicina e Escola Paulista de Enfermagem; Brazil), Francinne M Ribeiro (Hospital Universitário Pedro Ernesto Universidade do Estado do Rio de Janeiro; Brazil), Anne-Marie Chassin-Trubert (Complejo Hospitalario San José; Chile), Sebastián Ibáñez (Clínica Alemana de Santiago, Chile), Lingli Dong (Tongji Hospital, China)
Lui Cajas (Clinica Universitaria Colombia - Centro Medico Providencia Sanitas; Colombia), Hesham Hamoud (Al Azhar University Hospitals; Egypt), Jérôme Avouac (Rheumatology A Department, Cochin University Hospitals Paris-Centre, AP-HP; France), Véronique Belin (Department of Rheumatology, Hospital Center of Thonon-les-Bains; France), Raphaël Borie (Department of Pneumology, Bicha Hospital, AP-HP; France), Pascal Chazerain (Department of Rheumatology and Internal Medicine, Diaconesses Croix Saint Simon Hospital, Paris; France), Xavier Chevalier (Department of Rheumatology, Henri Mondor University Hospitals, AP-HP, Créteil; France), Pascal Claudepierre (Department of Rheumatology, Henri Mondor University Hospitals, AP-HP, Créteil; France), Gaëlle Clavel (Department of Internal Medicine, Rothschild Foundation, Paris; France), Marie-Eve Colette-Cedoz (Nord-Isère Rheumatology practice, Bourgoin-Jallieu; France), Bernard Combe (Department of Rheumatology, Lapeyronie University Hospital of Montpellier France), Elodie Constant (Department of Rheumatology, Hospital Center of Valence; France), Nathalie Costedoat-Chalumeau (Department of Internal Medicine, Cochin University Hospitals Paris-Centre, AP-HP; France), Marie Desmurs (Department of Rheumatology, Mulhouse-South Alsace hospital group; France), Valérie Devauchelle-Pensec (Rheumatology Department, Cavale Blanche Hospital and Brest Occidentale University; France), Mathilde Devaux (Department of Internal Medicine, Intercommunal Hospital Center of Poissy-Saint Germain; France), Robin Dhote (Department of Internal Medicine, Avicenne University Hospital, AP-HP, Paris; France), Yannick Dieudonné (Department of Internal Medicine and Clinical Immunology, Strasbourg University Hospital; France), Fanny Domont (Department of Internal Medicine and Clinical Immunology, Pitié-Salpêtrière Hospital, AP-HP; France), Pierre-Marie Duret (Department of Rheumatology, Colmar Civil Hospitals; France), Mikaël Ebbo (Department of Internal Medicine, La Timone Hospital, Aix-Marseille Univerity, AP-HM; France), Esther Ebstein (Department of Rheumatology, Bicha Hospital, AP-HP; France), Soumaya El Mahou (Department of Rheumatology and Internal Medicine, Hospital Center of Tourcoing; France), Bruno Fautrel (Department of Rheumatology, University Hospital Pitie Salpetriere, AP-HP, Paris; France), Renaud Felten (Department of Rheumatology, University Hospital of Strasbourg; France), René-Marc Flipo (Department of Rheumatology, University Hospital of Lille; France), Violaine Foltz (Department of Rheumatology, University Hospital Pitie Salpetriere, AP-HP; France), Antoine Froissart (Department of Internal Medicine, Intercommunal Hospital Center of Créteil; France), Joris Galland (Department of Internal Medicine, Lariboisière University Hospital, AP-HP, Paris; France), Véronique Gaud-Listrat (Rheumatology practice, Saint-Michel-sur-Orge; France), Sophie Georgin-Lavialle (Department of Internal Medicine, Tenon Hospital, AP-HP; France), Aude Giraud-Morelet (Val d'Ouest Clinical Medicine Center; France), Jeanine S Giraudet-Le Quitrec (Rheumatology A Department, Cochin University Hospitals Paris-Centre, AP-HP; France), Philippe Goupille (Department of Rheumatology, University Hospital of Tours; France), Sophie Govindaraju-Audouard (Rheumatology practice Les Haberges, Vesoul; France), Franck Grados (Department of Rheumatology, Amiens University Hospital; France), Séverine Guillaume-Czitrom (Department of Adolescent Medicine, University Hospital Paris-Sud, AP-HP, Le Kremlin-Bicêtre; France), Marion Hermet (Department of Internal Medicine, Hospital Center of Vichy; France), Ambre Hittinger-Roux (Department of Rheumatology, University Hospital of Reims; France), Christophe Hudry (Institute of Rheumatology Paris 8; France), Isabelle Kone-Paut (Department of Paediatric Rheumatology, University Hospital Paris-Sud, AP-HP, Le Kremlin-Bicêtre; France), Sylvain La Batide Alanore (Rheumatology practice, Paris; France), Pierre Lafforgue (Department of Rheumatology, Sainte-Marguerite Hospital, Aix-Marseille Univerity, AP-HM; France), Sophie Lahalle (Department of Rheumatology and Internal Medicine, Diaconesses Croix Saint Simon Hospital, Paris; France), Isabelle Lambrecht (Department of Rheumatology, Maison-Blanche Hospital, Reims University Hospitals; France), Vincent Langlois (Department of Infectious Diseases and Internal Medicine, Jacques Monod Hospital, Le Havre; France), Jean-Paul Larbre (Department of Rheumatology, Lyon-Sud Hospital, Hospices Civils Lyon; France), Emmanuel Ledoult (Department of Internal Medicine, Hospital Center of Tourcoing; France), Christophe Leroux (Department of Polyvalent Medicine, Dreux Hospital center; France), Frédéric Liote (Department of Rheumatology, Lariboisière University Hospital, AP-HP, Paris; France), Alexandre TJ Maria (Department of Internal Medicine and Multiorganic Diseases, Saint-Eloi University Hospital of Montpellier; France), Hubert Marotte (Department of Rheumatology, Saint-Etienne University Hospital; France), Arsène Mekinian (Department of Internal Medicine, Saint-Antoine Hospital, AP-HP, Paris; France), Isabelle Melki (Paediatric Hematology-Immunology and Rheumatology Department, Necker-Enfants-Malades University Hospital, AP-HP;France), Laurent Messer (Department of Rheumatology, Colmar Civil Hospitals; France), Catherine Michel (Department of Dermatology, Mulhouse-South Alsace hospital group; France), Gauthier Morel (Department of Rheumatology, Hospital Center of Valencienne; France), Jacques Morel (Department of Rheumatology, Lapeyronie University Hospital of Montpellier; France), Marie-Noelle Paris-Havard (Department of Rheumatology, Hospital Center of Argenteuil; France), Edouard Pertuiset (Department of Rheumatology, René Dubos Hospital Center, Pontoise; France), Thao Pham (Department of Rheumatology, Sainte-Marguerite Hospital, Aix-Marseille Univerity, AP-HM; France), Myriam Renard (Department of Rheumatology, Hospital Center of Aix-les-Bains, France), Sabine Revuz (Department of Internal Medicine and Clinical Immunology, Metz private Hospitals; France), Sébastien Rivière (Department of Internal Medicine and Inflammation-Immunopathology-Biotherapy, Saint-Antoine Hospital, AP-HP, Paris; France), Clémentine Rousselin (Department of Internal Medicine and Nephrology, Hospital Center of Valencienne; France), Christian Roux (Department of Rheumatology, Pasteur 2 University Hospital of Nice Sophia-Antipolis; France), Diane Rouzaud (Department of Internal Medicine, Bicha Hospital, AP-HP; France), Jérémie Sellam (Department of Rheumatology, Saint-Antoine Hospital, AP-HP, Paris; France), Raphaele Seror (Department of Rheumatology, University Hospitals Paris-Sud, AP-HP, Le Kremlin-Bicêtre; France), Amelie Servettaz (Department of Internal Medicine, University Hospital of Reims; France), Vincent Sobanski (Department of Internal Medicine and Clinical Immunology, University Hospital of Lille; France), Christelle Sordet (Department of Rheumatology, University Hospital of Strasbourg; France), Lionnel Spielmann (Department of Rheumatology, Colmar Civil Hospitals; France), Nathalie Tieulié (Department of Rheumatology, Pasteur 2 University Hospital of Nice Sophia-Antipolis; France), Alice Tison (Department of Rheumatology, University Hospital of Bordeaux; France), Sophie Trijau (Department of Rheumatology, Sainte-Marguerite Hospital, Aix-Marseille Univerity, AP-HM; France), Alexandre Virone (Department of Rheumatology, University Hospitals Paris-Sud, AP-HP, Le Kremlin-Bicêtre; France), Ursula Warzocha (Department of Internal Medicine, Avicenne University Hospital, AP-HP, Paris; France), Daniel Wendling (Department of Rheumatology, University Hospital of Besançon; France), Frederik N Albach (Department of Rheumatology and Clinical Immunology, Charité Universitätsmedizin, Berlin; Germany), Peer Aries (Rheumatology Struensee-Haus, Hamburg; Germany), Elvira Decker (Medical Care Center, Alsfeld; Germany), Urs Hartmann (Private Practice, Mainz; Germany), Joerg Henes (Department of Internal Medicine II, University of Tubingen; Germany), Bimba F Hoyer (University Hospital Schleswig-Holstein - Campus Kiel, Department of Rheumatology and Clinical Immunology, Clinic for Internal Medicine I; Germany), Andreas Krause (Immanuel Hospital Berlin, Department of Rheumatology, Clinical Immunology and Osteology; Germany), Klaus Krüger (Private Practice, Munich; Germany), Hanns-Martin Lorenz (University of Heidelberg, Department of Rheumatology; Germany), Ulf Müller-Ladner (Campus Kerckhoff, Justus-Liebig-University Giessen, Department of Rheumatology and Clinical Immunology; Germany), Alexander Pfeil (Department of Internal Medicine III, University Hospital Jena; Germany), Anne Regierer (German Rheumatism Research Center Berlin; Germany), Jutta G Richter (Heinrich-Heine-University, Medical Faculty, Department of Rheumatology and Hiller Research Unit; Germany), Markus Rihl (Private Practice, Traunstein; Germany), Tim Schmeiser (Private Practice, Cologne; Germany), Hendrik Schulze-Koops (University of Munich, Division of Rheumatology and Clinical Immunology, Department of Internal Medicine IV; Germany), Christof Specker (KEM Kliniken Essen-Mitte, Department of Rheumatology and Clinical Immunology; Germany), Reinhard E Voll (University Medical Center Freiburg, Department of Rheumatology and Clinical Immunology; Germany), Stephanie Werner (RHIO, Dusseldorf; Germany), Gabriela MG Melgar (Hospital del Valle; Honduras), Mahdi Vojdanian (Iran Rheumatology Center; Iran), Laura Andreoli (UO di Reumatologia ed Immunologia Clinica, Spedali Civili di Brescia; Italy), Elena Bartoloni-Bocci (University of Perugia; Italy), Maurizio Benucci (Ospedale civile San Giovanni di Dio; Italy), Francesco Campanaro (ASST Sette Laghi, Varese; Italy), Marta Caprioli (Rheumatology, Humanitas Clinical and Research Center – IRCCS; Italy), Davide Carboni (Azienda ospedaliero-universitaria Careggi; Italy), Greta Carrara (Italian Society for Rheumatology; Italy), Edoardo Cipolletta (Università Politecnica delle Marche; Italy), Chiara Crotti (ASST Gaetano Pini; Italy), Gloria Dallagiacoma (Ospedale di Brunico; Italy), Paola Faggioli (ASST ovest milanese legnano; Italy), Rosario Foti (Policlinico-Vitt. Emanuele; Policinico San Marco; Italy), Franco Franceschini (UO di Reumatologia ed Immunologia Clinica, Spedali Civili di Brescia Italy), Micaela Fredi (UO di Reumatologia ed Immunologia Clinica, Spedali Civili di Brescia; Italy), Giacomo Guidelli (Rheumatology, Humanitas Clinical and Research Center – IRCCS; Italy), Florenzo Iannone (University of Bari; Italy), Gianpiero Landolfi (Italian Society for Rheumatology; Italy), Caludia Lomater (Azienda Ospedaliera Ordine Mauriziano di Torino; Italy), Ceciclia Nalli (UO di Reumatologia ed Immunologia Clinica, Spedali Civili di Brescia; Italy), Simone Parisi (AOU Città della Salute e della Scienza; Italy), Luca Quartuccio (Università degli Studi di Udine; Italy), Bernd Raffeiner (Ospedale di Bolzano; Italy), Rossella Reggia (Ospedale Maggiore di Cremona; Italy), Marta Riva (Ospedale San Gerardo di Monza; Italy), Nicoletta Romeo (Azienda Ospedaliera Santa Croce e Carle di Cuneo; Italy), Cinzia Rotondo (Azienda Ospedaliero-Universitaria "Ospedali Riuniti" di Foggia; Italy), Ettore Silvagni (University of Ferrara; Italy), Luigi Sinigaglia (Italian Society for Rheumatology; Italy), Ilaria Tinazzi (Ospedale Sacro Cuore don Calabria di Negrar a Verona; Italy), Anna Zanetti (Italian Society for Rheumatology; Italy), Giovanni Zanframundo (Fondazione IRCCS Policlinico San Matteo di Pavia; Italy), Fatemah Abutiban (Kuwait Rheumatology Association; Kuwait), Deshiré Alpízar-Rodríguez (Mexican College of Rheumatology; Mexico), Marina Rull-Gabayet (Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán; Mexico), Fedra Irazoque (Private Practice; Mexico), Xochitl Jimenez (Centro Medico Naval; Mexico), Eduardo Martín-Nares (Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán; Mexico), Angel Castillo-Ortiz (Centro Medico Las Americas; Mexico), Tatiana S Rodriguez-Reyna (Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán; Mexico), Diana C Rosete (Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán; Mexico), Erick A Zamora-Tehozol (Centro Medico Pensiones; Mexico), David Vega-Morales (Hospital General de Zona #17; Mexico), Beatriz Elena Zaueta-Montiel (Centro Medico del Angel; Mexico), Rebecca Grainger (University of Otago, Wellington; New Zealand), Nasra Al-Adhoubi (Royal Hospital; Oman), Babur Salim (Fauji Foundation Hospital; Pakistan), Enrique Giraldo (Complejo Hospitalario; Panama), Ariel Salinas (Hospital Essalud Alberto Sabogal Sologuren; Peru), Manuel Ugarte-Gil (Universidad Científica del Sur-Hospital Guillermo Almenara Irigoyen; Peru), Diogo Almeida (Rheumatology Department, Unidade Local de Saúde do Alto Minho, Ponte de Lima; Portugal), Miguel Bernardes (Rheumatology Department, Centro Hopitalar São João, Porto; Portugal), Rita C Machado (Rheumatology and Metabolic Bone Diseases Department, Hospital de Santa Maria, CHLN, Lisbon Academic Medical Centre, Lisboa; Portugal), Maria Rato (Rheumatology Department, Centro Hopitalar São João, Porto; Portugal), Samar Al-Emadi (Hamad Medical Corporation; Qatar), Richard Conway (St. James's Hospital; Republic of Ireland), Rachael Flood (Tallaght University Hospital; Republic of Ireland), Juan J Alegre-Sancho (Hospital Universitari Dr Peset; Spain), Montserrat C Coro (complejo asistencial de Ávila; Spain), Natalia de la Torre-Rubio (Hospital Universitario Puerta de Hierro Majadahonda; Spain), Jose C Esteban (Hospital Universitario Puerta de Hierro; Spain), Maria del Carmen T Martin (HOSPITAL NUESTRA SEÑORA SONSOLES; Spain), Jose G Puerta (Hospital Clinic; Spain), Johan Back (Uppsala University Hospital, Uppsala; Sweden), Maryam Dastmalchi (Karolinska University Hospital, Stockholm; Sweden), Brigitte Dupré (Academic Specialist Center, Stockholm; Sweden), Emma Grenholm (Falu Lasarett, Region Dalarna, Falun; Sweden), Aase Hensvold (Academic Specialist Center, Stockholm; Sweden), Ann Knight (Uppsala University Hospital, Uppsala; Sweden), Servet Akar (Izmir Katip Celebi University Atatürk Training and Research Hospital; Turkey), Ozan C Icacan (Bakırköy Dr. Sadi Konuk Research and Training Hospital; Turkey), Laura Chadwick (St Helens & Knowsley NHS Trust; UK), Kirsty Devine (York Hospital; UK), Sasha Dunt (Countess of Chester NHS Foundation Trust; UK), Lucia Fusi (King's College Hospital; UK), Caroline M Jones (Llandudno Hospital; UK), Elizabeth Macphie (Lancashire and South Cumbria NHS Foundation Trust; UK), Elena Nikiphorou (King's College Hospital; UK), Diana O'Kane (Royal National Hospital For Rheumatic Diseases at Royal United Hospital; UK), Sheila O'Reilly (Royal Derby Hospital; UK), Samir Patel (Queen Elizabeth hospital; UK), Rosaria Salerno (King's College Hospital; UK), Lucy Thornton (Bradford Royal Infirmary; UK), Jenny Tyler (Royal United Hospital, Bath; UK), Claire Vandevelde (Leeds Teaching Hospitals Trust; UK), Elizabeth Warner (Lister Hospital; UK), Su-Ann Yeoh (University College London Hospitals NHS Foundation Trust; UK), Sara Baig (Arthritis and Rheumatology Consultants, PA; USA), Hammad Bajwa (Arthritis and Rheumatology Consultants, PA; USA), Byung Ban (Medstar Georgetown University Hospital; USA), Vernon Berglund (Arthritis and Rheumatology Consultants, PA; USA), Cassandra Calabrese (Cleveland Clinic; USA), Kristin D'Silva (Brigham and Women's Hospital; USA), Angela Dahle (Arthritis and Rheumatology Consultants, PA; USA), Kathryn Dao (UT Southwestern Medical Center; USA), Nicole Daver (Institute of Rheumatic and Autoimmune Diseases; USA), William Davis (Ochsner Medical Center Rheumatology Department; USA), Walter Dorman (Arthritis and Rheumatology Consultants, PA; USA), Ezzati Fatemeh (UT Southwestern Medical Center; USA), Theodore Fields (Hospital for Special Surgery; USA), Jody Hargrove (Arthritis and Rheumatology Consultants, PA; USA), Melissa Harvey (Institute of Rheumatic and Autoimmune Diseases; USA), Maren Hilton (Arthritis and Rheumatology Consultants, PA; USA), Tiffany Hsu (Brigham and Women's Hospital; USA), Zara Izadi (University of California, San Francisco, CA; USA), Arundathi Jayatilleke (Temple University Hospital; USA), David Karp (UT Southwestern Medical Center; USA), Gilbert Kepecs (Private Practice; USA), Neil Kramer (Institute of Rheumatic and Autoimmune Diseases; USA), Concetta Lamore (Institute of Rheumatic and Autoimmune Diseases; USA), Nicholas Lebedoff (Arthritis and Rheumatology Consultants, PA; USA), Susan Leonard (Arthritis and Rheumatology Consultants, PA;USA), Sushama Mody (Riverside Medical Group; USA), Jennifer Morgan (Arthritis and Rheumatology Consultants, PA; USA), Emily Pfeifer (Arthritis and Rheumatology Consultants, PA; USA), Guillermo Quiceno (UT Southwestern Medical Center; USA), Robert Quinet (Ochsner Medical Center Rheumatology Department; USA), Elliot Rosenstein (Institute of Rheumatic and Autoimmune Diseases; USA), Eric Ruderman (Northwestern Memorial; USA), Evangeline Scopelitis (Ochsner Medical Center Rheumatology Department; USA), Naomi Serling-Boyd (Brigham and Women's Hospital; USA), Faizah Siddique (Loyola University Medical Center; USA), Archibald Skemp (Arthritis and Rheumatology Consultants, PA; USA), Derrick Todd (Brigham and Women's Hospital; USA), Karen T Toribio (Ochsner Medical Center Rheumatology Department; USA), Rachel Wallwork (Brigham and Women's Hospital; USA), Tameka Webb-Detiege (Ochsner Medical Center Rheumatology Department; USA), Douglas White (Gundersen Health System; USA), Jeffrey Wilson (Arthritis and Rheumatology Consultants, PA; USA), Melanie Winter (Gundersen Health System; USA), Leanna Wise (Los Angeles County + USC Medical Center; USA), Anne Wolff (Arthritis and Rheumatology Consultants, PA; USA), Kristen Young (UT Southwestern Medical Center; USA), Jerald Zakem (Ochsner Medical Center Rheumatology Department; USA), JoAnn Zell (University of Colorado; USA), Kurt Zimmerman (Arthritis and Rheumatology Consultants, PA; USA).
Contributors: AS, MS and PMM had access to the study data, developed the figures and tables, and vouch for the data and analyses. MS performed the statistical analyses and contributed to data quality control, data analysis and interpretation of the data. AS, MG, SL-T, JL, LL, CR, MJS, GS, CAS, SA-A, JB-C, LC, RC, LG, EH, RH, KLH, ZI, PK and LK-F, contributed to data collection, data quality control, data analysis and interpretation of the data. EFM, JS, ES, PS, LT, ZSW, SB, WC, RG, JH and LJ contributed to data collection, data analysis and interpretation of the data. PCR, JY and PMM, directed the work, designed the data collection methods, contributed to data collection, data analysis and interpretation of the data, and had final responsibility for the decision to submit for publication. All authors contributed intellectual content during the drafting and revision of the work and approved the final version to be published.
Funding: Financial support from the American College of Rheumatology (ACR) and European League Against Rheumatism (EULAR).
Disclaimer: The views expressed here are those of the authors and participating members of the COVID-19 Global Rheumatology Alliance and do not necessarily represent the views of the American College of Rheumatology (ACR), the European League Against Rheumatism (EULAR), the (UK) National Health Service (NHS), the National Institute for Health Research (NIHR), or the (UK) Department of Health, or any other organisation.
Competing interests: AS reports personal fees from lectures for AbbVie, MSD, Roche, BMS and Pfizer, all outside the submitted work. MG reports grants from National Institutes of Health, NIAMS, outside the submitted work. JL reports a research grant from Pfizer, outside of the submitted work. EFM reports that LPCDR received support for specific activities: grants from Abbvie, Novartis, Janssen-Cilag, Lilly Portugal, Sanofi, Grünenthal S.A., MSD, Celgene, Medac, Pharmakern and GAfPA; grants and non-financial support from Pfizer; non-financial support from Grünenthal GmbH, outside the submitted work. CR has received consulting/speaker’s fees from Abbvie, Amgen, AstraZeneca, BMS, Biogen, Eli Lilly, Glenmark, GSK, MSD, Mylan and Pfizer, and grants from Biogen, Lilly and Nordic Pharma, all unrelated to this manuscript. MJS is supported by unrestricted grants from AbbVie, Biogen, Gilead, Lilly, MSD, Novartis and Pfizer. Her work is supported by grants from the National Institutes of Health and Agency for Healthcare Research and Quality. She leads the Data Analytic Center for the American College of Rheumatology, which is unrelated to this work. ES reports non-financial support from Canadian Arthritis Patient Alliance, outside the submitted work. JS is supported by the National Institute of Arthritis and Musculoskeletal and Skin Diseases (grant numbers K23 AR069688, R03 AR075886, L30 AR066953, P30 AR070253 and P30 AR072577), the Rheumatology Research Foundation (R Bridge Award), the Brigham Research Institute, and the R. Bruce and Joan M. Mickey Research Scholar Fund. He has received research support from Amgen and Bristol-Myers Squibb and performed consultancy for Bristol-Myers Squibb, Gilead, Inova Diagnostics, Janssen, Optum and Pfizer unrelated to this work. PS reports personal fees from American College of Rheumatology/Wiley Publishing, outside the submitted work. TT reports personal fees for lectures and expertises from Amgen, Arrow, Biogen, BMS, Chugai, Expanscience, Gilead, Grunenthal, LCA, Lilly, Medac, MSD, Nordic, Novartis, Pfizer, Sandoz, Sanofi, Theramex, Thuasne, TEVA and UCB, and reports financial support or fees for research activities from Amgen, Bone Therapeutics, Chugai, MSD, Novartis, Pfizer and UCB, all unrelated to this manuscript. ZSW reports grant support from Bristol-Myers Squibb and consulting fees from Viela Bio. JB-C has received consulting/speaker’s fees from Abbvie, MSD, BMS and Roche, and grants from Pfizer, all unrelated to this manuscript. He reports non-branded marketing campaigns for Novartis. PC has received consulting and lecturing fees from Abbvie, AstraZeneca, Bristol-Myers Squibb, Gilead, Glaxo Smith Kline, Innotech, Janssen, Merck Sharp Dohme, Roche, Servier and Vifor. LC has not received fees or personal grants from any laboratory, but her institute works by contract for laboratories among other institutions, such as Abbvie Spain, Eisai, Gebro Pharma, Merck Sharp & Dohme España, S.A., Novartis Farmaceutica, Pfizer, Roche Farma, Sanofi Aventis, Astellas Pharma, Actelion Pharmaceuticals España, Grünenthal GmbH and UCB Pharma. LG reports personal consultant fees from AbbVie, Amgen, BMS, Biogen, Celgene, Gilead, Janssen, Lilly, Novartis, Pfizer, Samsung Bioepis, Sanofi-Aventis and UCB, and grants from Amgen, Lilly, Janssen, Pfizer, Sandoz, Sanofi and Galapagos, all unrelated to this manuscript. RG reports non-financial support from Pfizer Australia, personal fees from Pfizer Australia, personal fees from Cornerstones, personal fees from Janssen New Zealand, non-financial support from Janssen Australia, personal fees from Novartis, outside the submitted work. EH reports personal consultant fees from Actelion, Sanofi-Genzyme and GSK, and grants from GSK, all unrelated to this manuscript. RH reports research grant from Pfizer and personal fees from AbbVie, Pfizer, Novartis, Amgen, Mylan, Gilead, Medac and Takeda, all outside the submitted work. JH reports grants from Rheumatology Research Foundation, grants from Childhood Arthritis and Rheumatology Research Alliance (CARRA), personal fees from Novartis, outside the submitted work. KLH reports she has received non-personal speaker’s fees from Abbvie and grant income from BMS, UCB and Pfizer, all unrelated to this manuscript. KLH is supported by the NIHR Manchester Biomedical Research Centre. PCR reports personal fees from Abbvie, Eli Lilly, Gilead, Janssen, Novartis, Pfizer, Roche and UCB, non-financial support from BMS, research funding from Janssen, Novartis, Pfizer and UCB, all outside the submitted work. JY reports consulting fees from AstraZeneca and Eli Lilly, and grants from Pfizer, outside the submitted work. PMM has received consulting/speaker’s fees from Abbvie, BMS, Celgene, Eli Lilly, Janssen, MSD, Novartis, Orphazyme, Pfizer, Roche and UCB, all unrelated to this manuscript, and is supported by the National Institute for Health Research (NIHR), University College London Hospitals (UCLH) and Biomedical Research Centre (BRC).
Provenance and peer review: Not commissioned; externally peer reviewed.
Supplemental material: This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise. | Fatal | ReactionOutcome | CC BY-NC | 33504483 | 19,510,868 | 2021-07 |
Give an alphabetized list of all active substances of drugs taken by the patient who experienced 'Infusion site induration'. | Changes in the subcutaneous tissue of catheterization site from the precatheterization state to the onset of anticancer drug-induced induration: A case report.
This case showed that anticancer drug administration induces unhealthy subcutaneous tissue (thrombus or edema) without subjective symptoms, abnormal sign by palpation, or inspection, which have an extravasation risk.
1 INTRODUCTION
This report presents some of the changes in the subcutaneous tissue at the site of catheter insertion of a patient undergoing chemotherapy. The site was observed by ultrasonography at 5 time points, namely, before insertion, immediately after treatment, after 1, 3, and 4 weeks.
Some practice guidelines do not recommend the use of a peripheral intravenous catheter for irritant or vesicant continuous administration to avoid vessel damage.
1
,
2
However, peripheral intravenous catheters are unavoidably used in some patients for drug administration because of their conditions, such as superior vena cava syndrome, coagulopathy, or compromised condition.
In clinical settings, induration can be observed at the catheterization sites after anticancer drug administration even without obvious signs and symptoms of extravasation such as feelings of tingling, burning, pain, swelling, and redness at the injection site.
2
,
3
A previous study reported the incidence of induration after chemotherapy as 17.4%. If induration is found by physicians or nurses, inserting catheter to the affected site is avoided. It can lead to catheter placement in inappropriate sites, such as the hands, near joints, or thin fragile veins.
4
These catheterization sites are reported as risk factors of extravasation. Thus, induration after anticancer drug administration is a clinical challenge for patients who must receive repetitive treatment using a peripheral intravenous catheter; induration occurrence should be prevented. It is important to know the actual condition of induration very well for safe chemotherapy treatment. Ultrasonography is used to observe the condition of the vein or surrounding tissue.
5
,
6
We already reported actual condition of induration through ultrasonography after obvious extravasation,
7
but the onset process of induration without obvious extravasation was unclear. Here, we report time course observation of the catheterization site from precatheterization to induration development through ultrasonography (Figure 1).
FIGURE 1 None
2 CASE DESCRIPTION
A 77‐year‐old man with esophagus cancer was receiving chemotherapy, paclitaxel, weekly through a peripheral intravenous catheter at a chemotherapy room in a university hospital in Japan. He was not diabetic and was not on anticoagulants or immunosuppressants. His body mass index was 18.5. Data of patient character and details of drugs administration method were collected from his medical chart.
No abnormal subcutaneous tissue condition was observed at the target site, which was confirmed through ultrasonography, prior to catheterization for the administration anticancer drug; on the second week of paclitaxel administration, diameter of the target vein was 2.4 mm. It was calculated by measuring the minor axis and major axis three times, and measurements were averaged. Then, the average of the minor axis was added to the average of major axis and divided by two. Also, the skin at the site of catheterization did not have any signs of abnormality upon inspection and palpation.
All ultrasound images were obtained by one researcher using a Noblus® with linear array (5‐18 MHz) 2D probe (Hitachi, Ltd, Medical). Precatheterization images were obtained by a 5‐cm swept probe (peripheral side 2.5 cm; center side 2.5 cm) with short axis over the point that nurses selected as catheterization site, along the vein. Ultrasonographic images were assessed with reference to previous studies;
5
,
6
unclear superficial fascia at surrounding vein was judged as subcutaneous edema presence, and ununiform echoic area in the intravascular lumen was judged as thrombus.
The nurse inserted a 24G catheter at the patient's cephalic vein on the right forearm. Location of the catheterization site was recorded by a measure and digital camera. Drug administration protocol was as follows: First, the nurse secured the catheterization site by administering normal saline solution; a 6.6 mg of dexamethasone sodium phosphate + 20 mg of famotidine + 5 mg of d‐Chlorpheniramine Maleate + 50 mL of normal saline was administered at 300 mL/h for 10 minutes. Next, 50 mL normal saline was administered at 300 mL/h for 10 minutes. Then, 156 mg paclitaxel + 50 mL normal saline was administrated at 300 mL/h for 60 minutes. Lastly, normal saline 30 mL at 300 mL/h for 6 minutes was administered. Thus, total drug administration time was about 90 minutes. Anticancer drug administration was completed without local adverse event or discomfort such as swelling, redness, and pain; however, subcutaneous edema and thrombus were observed through ultrasonography just after finishing anticancer drug administration (Figure 2A, B1, 2). Using ultrasonography, it was confirmed that the catheter tip was located in the vessel without stimulating the vessel wall.
FIGURE 2 A, Just before insertion a catheterization; Vein lumen area was imaged as anechoic area. B, Just after completing anticancer administration, and just before the catheter removal. Two high echo points shown by arrow are upper wall and lower wall of the catheter. Some high echo points at skin surface are reflection by a catheter securement film. (Refer B’: Illustration diagram.) There was no anechoic area; instead, vein lumen was imaged as nonuniform echoic area. It was considered thrombus presence. Also, uncleared superficial fascia was observed at the surrounding tissue of the vein. It was considered subcutaneous edema. C, Post‐treatment 1 wk; Ununiform echoic area remained in the vein lumen, and subcutaneous edema at surround tissue of the vein. There was nothing abnormal detected by palpation. D, Post‐treatment 3 wks; Ununiform echoic area remained in the vein lumen, and subcutaneous edema at surround tissue of the vein. Furthermore, induration was found by palpation in the site. E, Post‐treatment 4 wks; Unechoed area become clear in the vein lumen, but there was still remain thrombus and subcutaneous edema. Also, induration remained
One week later, no abnormal findings at the catheterization site were noted upon inspection or palpation. However, subcutaneous edema and the remaining thrombus at the site were observed, which were confirmed through ultrasonography. Three weeks later, the site was positively assessed for induration by palpation, and subcutaneous tissue and thrombus were observed through ultrasound. Four weeks later, the induration, thrombus, and subcutaneous edema were still present (Figure 2C‐E). No symptoms were observed upon inspection at any one time, and no subjective symptoms such as pain or sensations of burning were reported.
On the post‐treatment days, ultrasonographic images were taken same way as precatheterization, using puncture site or induration site as a center point. Evaluation of the presence of induration through palpation was conducted by a clinical nurse and one researcher who had clinical experience as a nurse.
Observation period was from February to March in 2019.
3 DISCUSSION AND CONCLUSION
We observed the target site from precatheterization time until the development of induration caused by chemotherapy drug administration through a peripheral intravenous catheter. This is the first study that reported time course observation of the catheterization site from precatheterization to induration development through ultrasonography.
Reports about peripheral intravenous catheterization‐induced induration are few; however, the condition of the subcutaneous tissue (thrombus, subcutaneous edema, and vessel wall thickening) in this case was the same as in a previous report. In that report, the induration sites were observed using ultrasonography, wherein the observation was only conducted on the next treatment day in patients who were receiving chemotherapy via peripheral intravenous catheters.
3
During precatheterization, no abnormal findings were observed on the skin and subcutaneous tissues including veins, and its diameter was enough to insert a 24G catheter.
8
In addition, the patient was not diabetic, was nonobese, and was not on any anticoagulants or immunosuppressants. Thus, we did not suspect a slow wound healing factor. There was no complication during drug administration, but subcutaneous edema and thrombus were confirmed upon finishing administration. A week later, induration was not observed at the site, even with the presence of subcutaneous edema and thrombus. However, induration with edema or thrombus was observed 3 weeks later. Above these reasons, induration caused by anticancer drug administration was due to the fibrotic subcutaneous tissue formation, which was a result of mild inflammation that did not induce pain, swelling, and erythema.
Inflammation may be induced by chemotherapy or catheter tip irritation to vessel walls. In this case, chemotherapeutic drugs might have induced induration due to inflammation. There are two reasons why we hold this clinical opinion. One, the catheter tip position was not in an irritating position to the vessel wall. The other reason is paclitaxel, which has been reported as a high stimulation drug, compared with other taxanes, such as docetaxel and nab‐paclitaxel.
9
Fibrosis which is the last part of inflammation reaction is formed gradually and lasts about a few weeks.
10
Thus, we consider that fibrosis had still not become advanced at 1‐week postchemotherapy. It means that in short treatment interval chemotherapy, there is possibility of anticancer drug administration using the site that has subcutaneous edema or thrombus as catheter placement site because nurses cannot detect abnormal tissue condition by palpation only.
“Unhealthy subcutaneous tissue” is one of the extravasation risk factors.
4
This case showed that anticancer drug administration through a peripheral intravenous catheter induces the development of unhealthy subcutaneous tissue (thrombus or edema) without subjective symptoms, abnormal sign by palpation, or inspection. Also, this case showed how subsequent anticancer drugs, including vesicants, may be infused at vulnerable sites. Continuous administration of irritants or vesicants via a central vein is recommended. However, for patients who unavoidably require peripheral intravenous catheters, the catheterization site must be carefully selected. Short‐term interval therapy such as a weekly chemotherapy has especially high risk for anticancer drug infusion at risky sites. Future researchers should consider the possibility of these risky sites when selecting appropriate catheterization site.
CONFLICT OF INTEREST
MA and RM belong to the laboratory supported by Terumo Co. CK and HS have no conflict of interest.
AUTHOR CONTRIBUTIONS
MA: designed the research. MA and CK: contributed to data collection. MA: drafted the manuscript. RM and HS: critically reviewed the manuscript and supervised the whole study process. All authors read and approved the final manuscript.
ETHICAL APPROVAL
This observation was conducted in accordance with the Declaration of Helsinki, and study protocol was approved by the Research Ethics Committee of the facility where researchers belong (No. 11650‐1). Using images and information for report was permitted by the patient.
ACKNOWLEDGMENTS
This study was supported by Japan Society for the Promotion of Science (Grant Number JP17H06645) and Yasuda Memorial Medical Foundation.
DATA AVAILABILITY STATEMENT
Research data are not shared. | PACLITAXEL | DrugsGivenReaction | CC BY-NC-ND | 33505685 | 18,886,507 | 2021-01 |
Give an alphabetized list of all active substances of drugs taken by the patient who experienced 'Infusion site oedema'. | Changes in the subcutaneous tissue of catheterization site from the precatheterization state to the onset of anticancer drug-induced induration: A case report.
This case showed that anticancer drug administration induces unhealthy subcutaneous tissue (thrombus or edema) without subjective symptoms, abnormal sign by palpation, or inspection, which have an extravasation risk.
1 INTRODUCTION
This report presents some of the changes in the subcutaneous tissue at the site of catheter insertion of a patient undergoing chemotherapy. The site was observed by ultrasonography at 5 time points, namely, before insertion, immediately after treatment, after 1, 3, and 4 weeks.
Some practice guidelines do not recommend the use of a peripheral intravenous catheter for irritant or vesicant continuous administration to avoid vessel damage.
1
,
2
However, peripheral intravenous catheters are unavoidably used in some patients for drug administration because of their conditions, such as superior vena cava syndrome, coagulopathy, or compromised condition.
In clinical settings, induration can be observed at the catheterization sites after anticancer drug administration even without obvious signs and symptoms of extravasation such as feelings of tingling, burning, pain, swelling, and redness at the injection site.
2
,
3
A previous study reported the incidence of induration after chemotherapy as 17.4%. If induration is found by physicians or nurses, inserting catheter to the affected site is avoided. It can lead to catheter placement in inappropriate sites, such as the hands, near joints, or thin fragile veins.
4
These catheterization sites are reported as risk factors of extravasation. Thus, induration after anticancer drug administration is a clinical challenge for patients who must receive repetitive treatment using a peripheral intravenous catheter; induration occurrence should be prevented. It is important to know the actual condition of induration very well for safe chemotherapy treatment. Ultrasonography is used to observe the condition of the vein or surrounding tissue.
5
,
6
We already reported actual condition of induration through ultrasonography after obvious extravasation,
7
but the onset process of induration without obvious extravasation was unclear. Here, we report time course observation of the catheterization site from precatheterization to induration development through ultrasonography (Figure 1).
FIGURE 1 None
2 CASE DESCRIPTION
A 77‐year‐old man with esophagus cancer was receiving chemotherapy, paclitaxel, weekly through a peripheral intravenous catheter at a chemotherapy room in a university hospital in Japan. He was not diabetic and was not on anticoagulants or immunosuppressants. His body mass index was 18.5. Data of patient character and details of drugs administration method were collected from his medical chart.
No abnormal subcutaneous tissue condition was observed at the target site, which was confirmed through ultrasonography, prior to catheterization for the administration anticancer drug; on the second week of paclitaxel administration, diameter of the target vein was 2.4 mm. It was calculated by measuring the minor axis and major axis three times, and measurements were averaged. Then, the average of the minor axis was added to the average of major axis and divided by two. Also, the skin at the site of catheterization did not have any signs of abnormality upon inspection and palpation.
All ultrasound images were obtained by one researcher using a Noblus® with linear array (5‐18 MHz) 2D probe (Hitachi, Ltd, Medical). Precatheterization images were obtained by a 5‐cm swept probe (peripheral side 2.5 cm; center side 2.5 cm) with short axis over the point that nurses selected as catheterization site, along the vein. Ultrasonographic images were assessed with reference to previous studies;
5
,
6
unclear superficial fascia at surrounding vein was judged as subcutaneous edema presence, and ununiform echoic area in the intravascular lumen was judged as thrombus.
The nurse inserted a 24G catheter at the patient's cephalic vein on the right forearm. Location of the catheterization site was recorded by a measure and digital camera. Drug administration protocol was as follows: First, the nurse secured the catheterization site by administering normal saline solution; a 6.6 mg of dexamethasone sodium phosphate + 20 mg of famotidine + 5 mg of d‐Chlorpheniramine Maleate + 50 mL of normal saline was administered at 300 mL/h for 10 minutes. Next, 50 mL normal saline was administered at 300 mL/h for 10 minutes. Then, 156 mg paclitaxel + 50 mL normal saline was administrated at 300 mL/h for 60 minutes. Lastly, normal saline 30 mL at 300 mL/h for 6 minutes was administered. Thus, total drug administration time was about 90 minutes. Anticancer drug administration was completed without local adverse event or discomfort such as swelling, redness, and pain; however, subcutaneous edema and thrombus were observed through ultrasonography just after finishing anticancer drug administration (Figure 2A, B1, 2). Using ultrasonography, it was confirmed that the catheter tip was located in the vessel without stimulating the vessel wall.
FIGURE 2 A, Just before insertion a catheterization; Vein lumen area was imaged as anechoic area. B, Just after completing anticancer administration, and just before the catheter removal. Two high echo points shown by arrow are upper wall and lower wall of the catheter. Some high echo points at skin surface are reflection by a catheter securement film. (Refer B’: Illustration diagram.) There was no anechoic area; instead, vein lumen was imaged as nonuniform echoic area. It was considered thrombus presence. Also, uncleared superficial fascia was observed at the surrounding tissue of the vein. It was considered subcutaneous edema. C, Post‐treatment 1 wk; Ununiform echoic area remained in the vein lumen, and subcutaneous edema at surround tissue of the vein. There was nothing abnormal detected by palpation. D, Post‐treatment 3 wks; Ununiform echoic area remained in the vein lumen, and subcutaneous edema at surround tissue of the vein. Furthermore, induration was found by palpation in the site. E, Post‐treatment 4 wks; Unechoed area become clear in the vein lumen, but there was still remain thrombus and subcutaneous edema. Also, induration remained
One week later, no abnormal findings at the catheterization site were noted upon inspection or palpation. However, subcutaneous edema and the remaining thrombus at the site were observed, which were confirmed through ultrasonography. Three weeks later, the site was positively assessed for induration by palpation, and subcutaneous tissue and thrombus were observed through ultrasound. Four weeks later, the induration, thrombus, and subcutaneous edema were still present (Figure 2C‐E). No symptoms were observed upon inspection at any one time, and no subjective symptoms such as pain or sensations of burning were reported.
On the post‐treatment days, ultrasonographic images were taken same way as precatheterization, using puncture site or induration site as a center point. Evaluation of the presence of induration through palpation was conducted by a clinical nurse and one researcher who had clinical experience as a nurse.
Observation period was from February to March in 2019.
3 DISCUSSION AND CONCLUSION
We observed the target site from precatheterization time until the development of induration caused by chemotherapy drug administration through a peripheral intravenous catheter. This is the first study that reported time course observation of the catheterization site from precatheterization to induration development through ultrasonography.
Reports about peripheral intravenous catheterization‐induced induration are few; however, the condition of the subcutaneous tissue (thrombus, subcutaneous edema, and vessel wall thickening) in this case was the same as in a previous report. In that report, the induration sites were observed using ultrasonography, wherein the observation was only conducted on the next treatment day in patients who were receiving chemotherapy via peripheral intravenous catheters.
3
During precatheterization, no abnormal findings were observed on the skin and subcutaneous tissues including veins, and its diameter was enough to insert a 24G catheter.
8
In addition, the patient was not diabetic, was nonobese, and was not on any anticoagulants or immunosuppressants. Thus, we did not suspect a slow wound healing factor. There was no complication during drug administration, but subcutaneous edema and thrombus were confirmed upon finishing administration. A week later, induration was not observed at the site, even with the presence of subcutaneous edema and thrombus. However, induration with edema or thrombus was observed 3 weeks later. Above these reasons, induration caused by anticancer drug administration was due to the fibrotic subcutaneous tissue formation, which was a result of mild inflammation that did not induce pain, swelling, and erythema.
Inflammation may be induced by chemotherapy or catheter tip irritation to vessel walls. In this case, chemotherapeutic drugs might have induced induration due to inflammation. There are two reasons why we hold this clinical opinion. One, the catheter tip position was not in an irritating position to the vessel wall. The other reason is paclitaxel, which has been reported as a high stimulation drug, compared with other taxanes, such as docetaxel and nab‐paclitaxel.
9
Fibrosis which is the last part of inflammation reaction is formed gradually and lasts about a few weeks.
10
Thus, we consider that fibrosis had still not become advanced at 1‐week postchemotherapy. It means that in short treatment interval chemotherapy, there is possibility of anticancer drug administration using the site that has subcutaneous edema or thrombus as catheter placement site because nurses cannot detect abnormal tissue condition by palpation only.
“Unhealthy subcutaneous tissue” is one of the extravasation risk factors.
4
This case showed that anticancer drug administration through a peripheral intravenous catheter induces the development of unhealthy subcutaneous tissue (thrombus or edema) without subjective symptoms, abnormal sign by palpation, or inspection. Also, this case showed how subsequent anticancer drugs, including vesicants, may be infused at vulnerable sites. Continuous administration of irritants or vesicants via a central vein is recommended. However, for patients who unavoidably require peripheral intravenous catheters, the catheterization site must be carefully selected. Short‐term interval therapy such as a weekly chemotherapy has especially high risk for anticancer drug infusion at risky sites. Future researchers should consider the possibility of these risky sites when selecting appropriate catheterization site.
CONFLICT OF INTEREST
MA and RM belong to the laboratory supported by Terumo Co. CK and HS have no conflict of interest.
AUTHOR CONTRIBUTIONS
MA: designed the research. MA and CK: contributed to data collection. MA: drafted the manuscript. RM and HS: critically reviewed the manuscript and supervised the whole study process. All authors read and approved the final manuscript.
ETHICAL APPROVAL
This observation was conducted in accordance with the Declaration of Helsinki, and study protocol was approved by the Research Ethics Committee of the facility where researchers belong (No. 11650‐1). Using images and information for report was permitted by the patient.
ACKNOWLEDGMENTS
This study was supported by Japan Society for the Promotion of Science (Grant Number JP17H06645) and Yasuda Memorial Medical Foundation.
DATA AVAILABILITY STATEMENT
Research data are not shared. | PACLITAXEL | DrugsGivenReaction | CC BY-NC-ND | 33505685 | 18,886,507 | 2021-01 |
Give an alphabetized list of all active substances of drugs taken by the patient who experienced 'Infusion site thrombosis'. | Changes in the subcutaneous tissue of catheterization site from the precatheterization state to the onset of anticancer drug-induced induration: A case report.
This case showed that anticancer drug administration induces unhealthy subcutaneous tissue (thrombus or edema) without subjective symptoms, abnormal sign by palpation, or inspection, which have an extravasation risk.
1 INTRODUCTION
This report presents some of the changes in the subcutaneous tissue at the site of catheter insertion of a patient undergoing chemotherapy. The site was observed by ultrasonography at 5 time points, namely, before insertion, immediately after treatment, after 1, 3, and 4 weeks.
Some practice guidelines do not recommend the use of a peripheral intravenous catheter for irritant or vesicant continuous administration to avoid vessel damage.
1
,
2
However, peripheral intravenous catheters are unavoidably used in some patients for drug administration because of their conditions, such as superior vena cava syndrome, coagulopathy, or compromised condition.
In clinical settings, induration can be observed at the catheterization sites after anticancer drug administration even without obvious signs and symptoms of extravasation such as feelings of tingling, burning, pain, swelling, and redness at the injection site.
2
,
3
A previous study reported the incidence of induration after chemotherapy as 17.4%. If induration is found by physicians or nurses, inserting catheter to the affected site is avoided. It can lead to catheter placement in inappropriate sites, such as the hands, near joints, or thin fragile veins.
4
These catheterization sites are reported as risk factors of extravasation. Thus, induration after anticancer drug administration is a clinical challenge for patients who must receive repetitive treatment using a peripheral intravenous catheter; induration occurrence should be prevented. It is important to know the actual condition of induration very well for safe chemotherapy treatment. Ultrasonography is used to observe the condition of the vein or surrounding tissue.
5
,
6
We already reported actual condition of induration through ultrasonography after obvious extravasation,
7
but the onset process of induration without obvious extravasation was unclear. Here, we report time course observation of the catheterization site from precatheterization to induration development through ultrasonography (Figure 1).
FIGURE 1 None
2 CASE DESCRIPTION
A 77‐year‐old man with esophagus cancer was receiving chemotherapy, paclitaxel, weekly through a peripheral intravenous catheter at a chemotherapy room in a university hospital in Japan. He was not diabetic and was not on anticoagulants or immunosuppressants. His body mass index was 18.5. Data of patient character and details of drugs administration method were collected from his medical chart.
No abnormal subcutaneous tissue condition was observed at the target site, which was confirmed through ultrasonography, prior to catheterization for the administration anticancer drug; on the second week of paclitaxel administration, diameter of the target vein was 2.4 mm. It was calculated by measuring the minor axis and major axis three times, and measurements were averaged. Then, the average of the minor axis was added to the average of major axis and divided by two. Also, the skin at the site of catheterization did not have any signs of abnormality upon inspection and palpation.
All ultrasound images were obtained by one researcher using a Noblus® with linear array (5‐18 MHz) 2D probe (Hitachi, Ltd, Medical). Precatheterization images were obtained by a 5‐cm swept probe (peripheral side 2.5 cm; center side 2.5 cm) with short axis over the point that nurses selected as catheterization site, along the vein. Ultrasonographic images were assessed with reference to previous studies;
5
,
6
unclear superficial fascia at surrounding vein was judged as subcutaneous edema presence, and ununiform echoic area in the intravascular lumen was judged as thrombus.
The nurse inserted a 24G catheter at the patient's cephalic vein on the right forearm. Location of the catheterization site was recorded by a measure and digital camera. Drug administration protocol was as follows: First, the nurse secured the catheterization site by administering normal saline solution; a 6.6 mg of dexamethasone sodium phosphate + 20 mg of famotidine + 5 mg of d‐Chlorpheniramine Maleate + 50 mL of normal saline was administered at 300 mL/h for 10 minutes. Next, 50 mL normal saline was administered at 300 mL/h for 10 minutes. Then, 156 mg paclitaxel + 50 mL normal saline was administrated at 300 mL/h for 60 minutes. Lastly, normal saline 30 mL at 300 mL/h for 6 minutes was administered. Thus, total drug administration time was about 90 minutes. Anticancer drug administration was completed without local adverse event or discomfort such as swelling, redness, and pain; however, subcutaneous edema and thrombus were observed through ultrasonography just after finishing anticancer drug administration (Figure 2A, B1, 2). Using ultrasonography, it was confirmed that the catheter tip was located in the vessel without stimulating the vessel wall.
FIGURE 2 A, Just before insertion a catheterization; Vein lumen area was imaged as anechoic area. B, Just after completing anticancer administration, and just before the catheter removal. Two high echo points shown by arrow are upper wall and lower wall of the catheter. Some high echo points at skin surface are reflection by a catheter securement film. (Refer B’: Illustration diagram.) There was no anechoic area; instead, vein lumen was imaged as nonuniform echoic area. It was considered thrombus presence. Also, uncleared superficial fascia was observed at the surrounding tissue of the vein. It was considered subcutaneous edema. C, Post‐treatment 1 wk; Ununiform echoic area remained in the vein lumen, and subcutaneous edema at surround tissue of the vein. There was nothing abnormal detected by palpation. D, Post‐treatment 3 wks; Ununiform echoic area remained in the vein lumen, and subcutaneous edema at surround tissue of the vein. Furthermore, induration was found by palpation in the site. E, Post‐treatment 4 wks; Unechoed area become clear in the vein lumen, but there was still remain thrombus and subcutaneous edema. Also, induration remained
One week later, no abnormal findings at the catheterization site were noted upon inspection or palpation. However, subcutaneous edema and the remaining thrombus at the site were observed, which were confirmed through ultrasonography. Three weeks later, the site was positively assessed for induration by palpation, and subcutaneous tissue and thrombus were observed through ultrasound. Four weeks later, the induration, thrombus, and subcutaneous edema were still present (Figure 2C‐E). No symptoms were observed upon inspection at any one time, and no subjective symptoms such as pain or sensations of burning were reported.
On the post‐treatment days, ultrasonographic images were taken same way as precatheterization, using puncture site or induration site as a center point. Evaluation of the presence of induration through palpation was conducted by a clinical nurse and one researcher who had clinical experience as a nurse.
Observation period was from February to March in 2019.
3 DISCUSSION AND CONCLUSION
We observed the target site from precatheterization time until the development of induration caused by chemotherapy drug administration through a peripheral intravenous catheter. This is the first study that reported time course observation of the catheterization site from precatheterization to induration development through ultrasonography.
Reports about peripheral intravenous catheterization‐induced induration are few; however, the condition of the subcutaneous tissue (thrombus, subcutaneous edema, and vessel wall thickening) in this case was the same as in a previous report. In that report, the induration sites were observed using ultrasonography, wherein the observation was only conducted on the next treatment day in patients who were receiving chemotherapy via peripheral intravenous catheters.
3
During precatheterization, no abnormal findings were observed on the skin and subcutaneous tissues including veins, and its diameter was enough to insert a 24G catheter.
8
In addition, the patient was not diabetic, was nonobese, and was not on any anticoagulants or immunosuppressants. Thus, we did not suspect a slow wound healing factor. There was no complication during drug administration, but subcutaneous edema and thrombus were confirmed upon finishing administration. A week later, induration was not observed at the site, even with the presence of subcutaneous edema and thrombus. However, induration with edema or thrombus was observed 3 weeks later. Above these reasons, induration caused by anticancer drug administration was due to the fibrotic subcutaneous tissue formation, which was a result of mild inflammation that did not induce pain, swelling, and erythema.
Inflammation may be induced by chemotherapy or catheter tip irritation to vessel walls. In this case, chemotherapeutic drugs might have induced induration due to inflammation. There are two reasons why we hold this clinical opinion. One, the catheter tip position was not in an irritating position to the vessel wall. The other reason is paclitaxel, which has been reported as a high stimulation drug, compared with other taxanes, such as docetaxel and nab‐paclitaxel.
9
Fibrosis which is the last part of inflammation reaction is formed gradually and lasts about a few weeks.
10
Thus, we consider that fibrosis had still not become advanced at 1‐week postchemotherapy. It means that in short treatment interval chemotherapy, there is possibility of anticancer drug administration using the site that has subcutaneous edema or thrombus as catheter placement site because nurses cannot detect abnormal tissue condition by palpation only.
“Unhealthy subcutaneous tissue” is one of the extravasation risk factors.
4
This case showed that anticancer drug administration through a peripheral intravenous catheter induces the development of unhealthy subcutaneous tissue (thrombus or edema) without subjective symptoms, abnormal sign by palpation, or inspection. Also, this case showed how subsequent anticancer drugs, including vesicants, may be infused at vulnerable sites. Continuous administration of irritants or vesicants via a central vein is recommended. However, for patients who unavoidably require peripheral intravenous catheters, the catheterization site must be carefully selected. Short‐term interval therapy such as a weekly chemotherapy has especially high risk for anticancer drug infusion at risky sites. Future researchers should consider the possibility of these risky sites when selecting appropriate catheterization site.
CONFLICT OF INTEREST
MA and RM belong to the laboratory supported by Terumo Co. CK and HS have no conflict of interest.
AUTHOR CONTRIBUTIONS
MA: designed the research. MA and CK: contributed to data collection. MA: drafted the manuscript. RM and HS: critically reviewed the manuscript and supervised the whole study process. All authors read and approved the final manuscript.
ETHICAL APPROVAL
This observation was conducted in accordance with the Declaration of Helsinki, and study protocol was approved by the Research Ethics Committee of the facility where researchers belong (No. 11650‐1). Using images and information for report was permitted by the patient.
ACKNOWLEDGMENTS
This study was supported by Japan Society for the Promotion of Science (Grant Number JP17H06645) and Yasuda Memorial Medical Foundation.
DATA AVAILABILITY STATEMENT
Research data are not shared. | PACLITAXEL | DrugsGivenReaction | CC BY-NC-ND | 33505685 | 18,886,507 | 2021-01 |
What was the administration route of drug 'PACLITAXEL'? | Changes in the subcutaneous tissue of catheterization site from the precatheterization state to the onset of anticancer drug-induced induration: A case report.
This case showed that anticancer drug administration induces unhealthy subcutaneous tissue (thrombus or edema) without subjective symptoms, abnormal sign by palpation, or inspection, which have an extravasation risk.
1 INTRODUCTION
This report presents some of the changes in the subcutaneous tissue at the site of catheter insertion of a patient undergoing chemotherapy. The site was observed by ultrasonography at 5 time points, namely, before insertion, immediately after treatment, after 1, 3, and 4 weeks.
Some practice guidelines do not recommend the use of a peripheral intravenous catheter for irritant or vesicant continuous administration to avoid vessel damage.
1
,
2
However, peripheral intravenous catheters are unavoidably used in some patients for drug administration because of their conditions, such as superior vena cava syndrome, coagulopathy, or compromised condition.
In clinical settings, induration can be observed at the catheterization sites after anticancer drug administration even without obvious signs and symptoms of extravasation such as feelings of tingling, burning, pain, swelling, and redness at the injection site.
2
,
3
A previous study reported the incidence of induration after chemotherapy as 17.4%. If induration is found by physicians or nurses, inserting catheter to the affected site is avoided. It can lead to catheter placement in inappropriate sites, such as the hands, near joints, or thin fragile veins.
4
These catheterization sites are reported as risk factors of extravasation. Thus, induration after anticancer drug administration is a clinical challenge for patients who must receive repetitive treatment using a peripheral intravenous catheter; induration occurrence should be prevented. It is important to know the actual condition of induration very well for safe chemotherapy treatment. Ultrasonography is used to observe the condition of the vein or surrounding tissue.
5
,
6
We already reported actual condition of induration through ultrasonography after obvious extravasation,
7
but the onset process of induration without obvious extravasation was unclear. Here, we report time course observation of the catheterization site from precatheterization to induration development through ultrasonography (Figure 1).
FIGURE 1 None
2 CASE DESCRIPTION
A 77‐year‐old man with esophagus cancer was receiving chemotherapy, paclitaxel, weekly through a peripheral intravenous catheter at a chemotherapy room in a university hospital in Japan. He was not diabetic and was not on anticoagulants or immunosuppressants. His body mass index was 18.5. Data of patient character and details of drugs administration method were collected from his medical chart.
No abnormal subcutaneous tissue condition was observed at the target site, which was confirmed through ultrasonography, prior to catheterization for the administration anticancer drug; on the second week of paclitaxel administration, diameter of the target vein was 2.4 mm. It was calculated by measuring the minor axis and major axis three times, and measurements were averaged. Then, the average of the minor axis was added to the average of major axis and divided by two. Also, the skin at the site of catheterization did not have any signs of abnormality upon inspection and palpation.
All ultrasound images were obtained by one researcher using a Noblus® with linear array (5‐18 MHz) 2D probe (Hitachi, Ltd, Medical). Precatheterization images were obtained by a 5‐cm swept probe (peripheral side 2.5 cm; center side 2.5 cm) with short axis over the point that nurses selected as catheterization site, along the vein. Ultrasonographic images were assessed with reference to previous studies;
5
,
6
unclear superficial fascia at surrounding vein was judged as subcutaneous edema presence, and ununiform echoic area in the intravascular lumen was judged as thrombus.
The nurse inserted a 24G catheter at the patient's cephalic vein on the right forearm. Location of the catheterization site was recorded by a measure and digital camera. Drug administration protocol was as follows: First, the nurse secured the catheterization site by administering normal saline solution; a 6.6 mg of dexamethasone sodium phosphate + 20 mg of famotidine + 5 mg of d‐Chlorpheniramine Maleate + 50 mL of normal saline was administered at 300 mL/h for 10 minutes. Next, 50 mL normal saline was administered at 300 mL/h for 10 minutes. Then, 156 mg paclitaxel + 50 mL normal saline was administrated at 300 mL/h for 60 minutes. Lastly, normal saline 30 mL at 300 mL/h for 6 minutes was administered. Thus, total drug administration time was about 90 minutes. Anticancer drug administration was completed without local adverse event or discomfort such as swelling, redness, and pain; however, subcutaneous edema and thrombus were observed through ultrasonography just after finishing anticancer drug administration (Figure 2A, B1, 2). Using ultrasonography, it was confirmed that the catheter tip was located in the vessel without stimulating the vessel wall.
FIGURE 2 A, Just before insertion a catheterization; Vein lumen area was imaged as anechoic area. B, Just after completing anticancer administration, and just before the catheter removal. Two high echo points shown by arrow are upper wall and lower wall of the catheter. Some high echo points at skin surface are reflection by a catheter securement film. (Refer B’: Illustration diagram.) There was no anechoic area; instead, vein lumen was imaged as nonuniform echoic area. It was considered thrombus presence. Also, uncleared superficial fascia was observed at the surrounding tissue of the vein. It was considered subcutaneous edema. C, Post‐treatment 1 wk; Ununiform echoic area remained in the vein lumen, and subcutaneous edema at surround tissue of the vein. There was nothing abnormal detected by palpation. D, Post‐treatment 3 wks; Ununiform echoic area remained in the vein lumen, and subcutaneous edema at surround tissue of the vein. Furthermore, induration was found by palpation in the site. E, Post‐treatment 4 wks; Unechoed area become clear in the vein lumen, but there was still remain thrombus and subcutaneous edema. Also, induration remained
One week later, no abnormal findings at the catheterization site were noted upon inspection or palpation. However, subcutaneous edema and the remaining thrombus at the site were observed, which were confirmed through ultrasonography. Three weeks later, the site was positively assessed for induration by palpation, and subcutaneous tissue and thrombus were observed through ultrasound. Four weeks later, the induration, thrombus, and subcutaneous edema were still present (Figure 2C‐E). No symptoms were observed upon inspection at any one time, and no subjective symptoms such as pain or sensations of burning were reported.
On the post‐treatment days, ultrasonographic images were taken same way as precatheterization, using puncture site or induration site as a center point. Evaluation of the presence of induration through palpation was conducted by a clinical nurse and one researcher who had clinical experience as a nurse.
Observation period was from February to March in 2019.
3 DISCUSSION AND CONCLUSION
We observed the target site from precatheterization time until the development of induration caused by chemotherapy drug administration through a peripheral intravenous catheter. This is the first study that reported time course observation of the catheterization site from precatheterization to induration development through ultrasonography.
Reports about peripheral intravenous catheterization‐induced induration are few; however, the condition of the subcutaneous tissue (thrombus, subcutaneous edema, and vessel wall thickening) in this case was the same as in a previous report. In that report, the induration sites were observed using ultrasonography, wherein the observation was only conducted on the next treatment day in patients who were receiving chemotherapy via peripheral intravenous catheters.
3
During precatheterization, no abnormal findings were observed on the skin and subcutaneous tissues including veins, and its diameter was enough to insert a 24G catheter.
8
In addition, the patient was not diabetic, was nonobese, and was not on any anticoagulants or immunosuppressants. Thus, we did not suspect a slow wound healing factor. There was no complication during drug administration, but subcutaneous edema and thrombus were confirmed upon finishing administration. A week later, induration was not observed at the site, even with the presence of subcutaneous edema and thrombus. However, induration with edema or thrombus was observed 3 weeks later. Above these reasons, induration caused by anticancer drug administration was due to the fibrotic subcutaneous tissue formation, which was a result of mild inflammation that did not induce pain, swelling, and erythema.
Inflammation may be induced by chemotherapy or catheter tip irritation to vessel walls. In this case, chemotherapeutic drugs might have induced induration due to inflammation. There are two reasons why we hold this clinical opinion. One, the catheter tip position was not in an irritating position to the vessel wall. The other reason is paclitaxel, which has been reported as a high stimulation drug, compared with other taxanes, such as docetaxel and nab‐paclitaxel.
9
Fibrosis which is the last part of inflammation reaction is formed gradually and lasts about a few weeks.
10
Thus, we consider that fibrosis had still not become advanced at 1‐week postchemotherapy. It means that in short treatment interval chemotherapy, there is possibility of anticancer drug administration using the site that has subcutaneous edema or thrombus as catheter placement site because nurses cannot detect abnormal tissue condition by palpation only.
“Unhealthy subcutaneous tissue” is one of the extravasation risk factors.
4
This case showed that anticancer drug administration through a peripheral intravenous catheter induces the development of unhealthy subcutaneous tissue (thrombus or edema) without subjective symptoms, abnormal sign by palpation, or inspection. Also, this case showed how subsequent anticancer drugs, including vesicants, may be infused at vulnerable sites. Continuous administration of irritants or vesicants via a central vein is recommended. However, for patients who unavoidably require peripheral intravenous catheters, the catheterization site must be carefully selected. Short‐term interval therapy such as a weekly chemotherapy has especially high risk for anticancer drug infusion at risky sites. Future researchers should consider the possibility of these risky sites when selecting appropriate catheterization site.
CONFLICT OF INTEREST
MA and RM belong to the laboratory supported by Terumo Co. CK and HS have no conflict of interest.
AUTHOR CONTRIBUTIONS
MA: designed the research. MA and CK: contributed to data collection. MA: drafted the manuscript. RM and HS: critically reviewed the manuscript and supervised the whole study process. All authors read and approved the final manuscript.
ETHICAL APPROVAL
This observation was conducted in accordance with the Declaration of Helsinki, and study protocol was approved by the Research Ethics Committee of the facility where researchers belong (No. 11650‐1). Using images and information for report was permitted by the patient.
ACKNOWLEDGMENTS
This study was supported by Japan Society for the Promotion of Science (Grant Number JP17H06645) and Yasuda Memorial Medical Foundation.
DATA AVAILABILITY STATEMENT
Research data are not shared. | Intravenous (not otherwise specified) | DrugAdministrationRoute | CC BY-NC-ND | 33505685 | 18,886,507 | 2021-01 |
Give an alphabetized list of all active substances of drugs taken by the patient who experienced 'Maternal exposure during pregnancy'. | Carbamazepine-induced Stevens-Johnson syndrome in a patient with history of methotrexate-induced mast cell activation syndrome.
Stevens-Johnson syndrome (SJS) is serious conditions that happen as a result of infection, side effects to medications, or unknown etiology. Carbamazepine is one of the common medications that can cause SJS. Good history taking is crucial if treatment with carbamazepine is clinically indicated. We would like to alert all physicians that carbamazepine should be avoided in any patient with a previous history of drug reaction such as mast cell activation syndrome.
1 CASE REPORT
A 42‐year‐old woman was presented to the hospital with history of methotrexate‐induced pruritus and severe skin reaction. She had ectopic pregnancy 2 years ago and was treated with methotrexate after which she developed severe stomatitis, leucopenia, and severe inflammation of urinary bladder, diagnosed as mast cell activation syndrome at that time. Recently, she was admitted to the critical care unit as a case of SJS with fever, generalized macular rash, buccal ulceration, and burning sensation in her eyes. Further history revealed that she started treatment with carbamazepine 2 weeks before admission treating trigeminal neuralgia. The medical history was otherwise unremarkable. On physical examination, there are several flaccid and ruptured bullae on the Rt hand, back, and legs, and generalized maculopapular rash with target lesions all over the body in centrifugal distribution (Figures 1 and 2). Total area of skin involvement was <10%. Nikolsky's sign was positive (Figure 3). There are erythema and painful erosions on both lips (Figure 4). Patient complain of odynophagia but able to swallow some liquids with involvement of genital mucosa.
FIGURE 1 Generalised maculopapular rash on both hands
FIGURE 2 Generalised maculopapular rash with target lesions on lower limbs
FIGURE 3 Nikolsky's sign
FIGURE 4 Erythema and erosion on both lips
Laboratory investigations showed mild leukopenia, no eosinophilia, and thrombocytopenia with mildly elevated aspartate aminotransferase (AST), alanine aminotransferase (ALT), and C‐reactive protein (CRP). No symptoms or signs of infection were found with negative blood, urine, and sputum cultures. No skin biopsy was taken.
Patient was admitted to the critical care unit, and carbamazepine was discontinued immediately; patient received intravenous fluid maintaining positive balance, nutritional support, eye care, and wound care.
Steroid treatment was given for 5 days in the form of 40 milligram methyl prednisolone daily. On the 10th day, patient was discharged.
Laboratory results
Blood test results
WBCs (white blood counts) = 3600
HB (hemoglobin) = 13.4 g
Platelets = 103 000
Urea = 15 mg/dL
Creatinine = 1 mg/dL
ALT = 61.9 U/L
AST = 55.1 U/L
GGT = 109 U/L
CRP = 47.3 mg/L
2 DISCUSSION
Stevens‐Johnson syndrome (SJS) is a severe mucocutaneous reaction, most commonly triggered by medications and infection, and in 1 of 3 cases, no cause was identified. There are extensive necrosis and detachment of the epidermis.
1
Mucous membranes are usually affected in more than 90% of cases. Both SJS and TEN are distinguished chiefly by severity, based upon the percentage of blisters and erosions.
2
,
3
Medications are main trigger of SJS, especially allopurinol and antiepileptic medications.
4
,
5
The pathology of Stevens‐Johnson syndrome is incompletely understood. Studies suggested a cell‐mediated reaction against keratinocytes leading to necrosis.
6
Drugs can stimulate the immune system by binding to the major histocompatibility complex (MHC) class I and the T‐cell receptor. The hallmark of SJS is the keratinocyte necrosis, ranging from partial‐ to full‐thickness necrosis of the epidermis.
7
,
8
For patients with suspected drug‐induced SJS, withdrawal of the offending agent may improve the prognosis. In one observational study of 113 patients with SJS, early drug withdrawal reduced the risk of death by 30 percent for each day before the development of blisters and erosions.
9
The main lines of management include fluid and electrolyte management, wound care, nutritional support, pain control, temperature management, and treatment of infections.
10
,
11
There are no definitive therapies for SJS.
12
,
13
Several immunosuppressive or immunomodulating therapies have been used in clinical practice, including systemic corticosteroids, intravenous immune globulin (IVIG), cyclosporine, plasmapheresis, and antitumor necrosis factor (TNF) monoclonal antibodies.
None of these therapies have been adequately studied in randomized trials except thalidomide, which was found to be harmful.
14
The use of systemic corticosteroids in patients with SJS has not been evaluated in clinical trials and remains controversial.
15
Another immunologically medicated disorders is mast cell activation syndrome (MCAS), which is one of mast cell disorders present with signs and symptoms that are caused either by activation of mast cells or by mast cells infiltrating organs.
16
Mast cell activation syndrome (MCAS) was first proposed as a distinct idiopathic disorder in 2010.
17
Subsequently, the definition of MCAS expanded to also include primary and secondary categories, making "mast cell activation syndrome" essentially an umbrella term that describes a clinical presentation, rather than a specific diagnosis.
18
In our case, the patient was diagnosed earlier with mast cell activation syndrome with pruritus and severe skin reaction; 2 years later, the patient was prescribed carbamazepine treating trigeminal neuralgia; the history of drug‐induced immunologically mediated mast cell activation with skin pruritus was missed; and patient developed severe form of SJS Good history taking is crucial if treatment with carbamazepine is clinically indicated. We would like to alert all physicians that carbamazepine should be avoided in any patient with a previous history of drug reaction such as mast cell activation syndrome.
3 CONCLUSION
Stevens‐Johnson syndrome (SJS) is very serious skin condition. Carbamazepine is one of the common medications that can cause (SJS). Good history taking is crucial if treatment with carbamazepine is clinically indicated. Physicians should be alert to avoid carbamazepine in any patient with a previous history of drug reaction such as mast cell activation syndrome.
CONFLICT OF INTEREST
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
AUTHOR CONTRIBUTIONS
TZ: wrote the article. ZIB and OSM: shared in the discussion. MA: collected data and revised the manuscript. All authors reviewed the final draft of the manuscript and approved its submission.
CONSENT
Informed consent was obtained from the patient for the publication of this clinical image. | METHOTREXATE | DrugsGivenReaction | CC BY | 33505688 | 18,639,004 | 2021-01 |
Give an alphabetized list of all active substances of drugs taken by the patient who experienced 'Hypertensive emergency'. | Scleroderma Renal Crisis in a Case of Mixed Connective Tissue Disease Treated Successfully with Angiotensin-Converting Enzyme Inhibitors.
Mixed connective tissue disease (MCTD) is a rheumatic disease syndrome with overlapping features of scleroderma, systemic lupus erythematosus, and polymyositis. An extremely rare but serious complication that can occur in MCTD is scleroderma renal crisis (SRC). There have been different approaches to the treatment of SRC associated with MCTD. We present a case of MCTD with chronic features of Raynaud's phenomenon, dermatomyositis, and thrombocytopenia complicated with acute SRC which showed a great response to ACE inhibitors. Here, we advise the early and aggressive use of ACE inhibitors as soon as SRC is suspected.
1. Introduction
Mixed connective tissue disease (MCTD) is a rheumatic disease syndrome originally described in 1972 and applied to patients with overlapping clinical features of systemic sclerosis (scleroderma), systemic lupus erythematosus (SLE), and polymyositis along with the presence of high titers of a distinctive antibody to the U1 ribonucleoprotein (U1 RNP) [1, 2]. Clinical features of high frequency include Raynaud's phenomenon, arthralgias, swollen hands, fingers with a sausage-like appearance, esophageal dysfunction, and muscle weakness. MCTD can potentially affect various organ systems resulting in pulmonary, renal, cardiovascular, gastrointestinal, and central nervous system manifestations [3, 4]. Scleroderma renal crisis (SRC) is an extremely rare complication in MCTD [5, 6]. It typically presents as an accelerated hypertension of sudden onset and acute renal injury, with or without microangiopathic hemolytic anemia or thrombocytopenia [5, 7, 8]. Several reports have emphasized the use of angiotensin-converting enzyme inhibitors (ACEi) and their dramatic improvement on the outcomes and survival of scleroderma patients experiencing SRC [8–11]. However, only a few reports on the treatment of SRC in MCTD exist [5, 6, 12]. In this article, we report a rare case of MCTD complicated by SRC which was treated successfully with ACEi.
2. Case Report
This is a case of a 30-year-old female with a history of MCTD. She had been diagnosed with MCTD with a positive ANA: >3.5 U (3–5.9 U is positive, ≥6 is strongly positive) and high titers of anti-RNP antibody: 208.8 IU (anti-RNP > 26 U is positive) associated with Raynaud's phenomenon, dermatomyositis, chronic thrombocytopenia, and chronic arthralgia 4 months prior to her presentation. Since then, she was treated with azathioprine, prednisone, nifedipine, and naproxen. The patient was brought to the emergency room (ER) after she had experienced two syncopal episodes. Five days prior to admission, she developed a fever (Tmax: 102 F, 38.8 C) associated with recurrent nausea and vomiting. She also reported dyspnea on exertion, palpitations, and myalgia. Despite negative urinary symptoms, she was diagnosed with a urinary tract infection (UTI) based on the urinalysis (UA) findings of pyuria, hematuria, and +2 proteinuria at that time. She had no diarrhea, abdominal pain, chest pain, or new active skin changes.
Initial physical examination in the ER showed the patient to be alert and oriented. Vital signs showed heart rate (HR) of 110 bpm and blood pressure (BP) of 160/108 mmHg. Based on the clinical picture and laboratory findings, she was thought to be dehydrated and 2 liters of 0.9% saline was given intravenously. Two hours later, she developed sudden tachypnea and dyspnea with hypoxaemia and elevated BP (systolic 220 over diastolic 115) that eventually required intubation for acute hypoxemic respiratory failure. Chest X-ray (CXR) findings were consistent with bilateral pulmonary edema. The patient was placed on nitroglycerine (NG) infusion and transferred to the medical intensive care unit for further management.
Laboratory workup on admission: WBC 8.9 × 10^9/L (4–11 × 10^9), hemoglobin 13.5 g/dl (12–15 g/dL), hematocrit 40.4% (36%–47%), platelet count 165 103/uL (150–400 × 10^9), serum creatinine (sCr) 1.18 mg/dL (baseline sCR was 0.56 mg/dL), serum bicarbonate 17 mmol/L (18–22 mmol/L), plasma renin activity (PRA) 143.5 ng/mL/hour (normal is ≤ 0.6–4.3 ng/mL/hour), potassium 2.3 mmol/L (3.5–5 mmol/L), haptoglobin 11 mg/dL (50–220 mg/dL), C-reactive protein (CRP) 1.9 mg/L (<5 mg/L), ESR 40 mm/hour (normal is < age/2 mm/hour), serum lactate dehydrogenase 423 U/L (50–150 U/L), arterial pH 7.08 (7.35–7.45), arterial pO2 68 mmHg (75–100 mmHg), and arterial HCO3 13.3 mmol/L (18–22 mmHg). Urinalysis showed pyuria, proteinuria, and hematuria including RBC casts and dysmorphic RBCs. The patient was found to be oliguric after monitoring urine output for 24 hours (total urine output was 215 ml). Spot protein/Cr ratio was 3.2.
Despite improvement in BP readings (with an IV antihypertensive medication), the patient remained oliguric and sCr continued to rise, peaking at 1.62 mg/dL, which is 3 times her baseline sCr. Given the history of MCTD along with the typical presentation of a possible SRC-like syndrome, the decision was made to initiate Captopril. Within 24 hours from starting captopril, urine output started to increase and oliguria resolved with improvement in renal function as shown in Figure 1. We titrated up the captopril and were able to wean off nicardipine.
On the third day, once the patient was hemodynamically stable and blood pressure was under control, the decision was made to perform a renal biopsy for further workup. It showed thrombotic microangiopathic changes in the interlobular arteries which are consistent with SRC-like syndrome as seen in Figures 2–5. A day later, the patient was successfully extubated. A week later, the patient was discharged with sCr of 0.88 mg/dL and in good condition with the impression of a SRC-like syndrome in MCTD.
3. Discussion
The exact prevalence and incidence of MCTD remain unknown. However, it has always been reported to be more common in females despite the difference in ratios estimated by different studies [13–15].
Being an overlap syndrome, the definitive diagnosis of MCTD can be difficult to achieve [16]. The early clinical manifestations are nonspecific and the disease state is considered an undifferentiated connective tissue disease (UCTD) [16–18]. During this stage, patients commonly complain of fatigue, myalgias, arthralgias, and Raynaud's phenomenon [16]. Findings suggestive of MCTD occur sequentially evolving over the years [16, 17, 19]. The presence of Raynaud's phenomenon and high titers of anti-U1 RNP antibodies are strong predictors of future evolution to MCTD [16, 19].
As MCTD was initially described in 1972, it was thought to be a connective tissue disease syndrome that is of favourable prognosis and excellent responsiveness to corticosteroid therapy compared to other connective tissue diseases (CTD) [1]. It was suggested that antibodies to ENA (i.e., U1 RNP), which are distinct to MCTD, have a protective role [1]. At that time, renal involvement in MCTD had not yet been identified. However, since then, as more cases of MCTD were being reported, findings of cardiac, pulmonary, and renal involvement emerged and did not have as much of a favourable prognosis as initially perceived.
Multiple criteria (Sharp, Alarcon–Segovia, Khan, Kasukawa) were established for the diagnosis of MCTD based on the serological findings of high-titer-anti-U1 RNP antibodies accompanied by other clinical features of the disease. One study showed that the Alarcon–Segovia's criteria had a sensitivity and specificity of 63% and 86%, respectively [14].
Renal involvement in MCTD is uncommon (10%–26% of patients) and is often asymptomatic [5]. In a study looking at the renal involvement in MCTD, it was found that the only early indicator of renal disease was an abnormal urinalysis with no overt clinical features. Serologic studies were not a helpful predictor either. Renal involvement can occur as glomerulonephritis (GN), nephrotic syndrome, amyloidosis, and, rarely, the renal vasculopathy characteristic of scleroderma, hence the name scleroderma renal crisis (SRC) [12, 20].
SRC in scleroderma occurs in 5–10% of patients [21]. However, in MCTD, it is a severe complication that has rarely been reported [3, 5, 6, 22, 23]. It typically presents as a sudden onset of accelerated hypertension (which could often be malignant) and acute renal injury with or without microangiopathic hemolytic anemia or thrombocytopenia [1, 7, 20].
The biochemical picture of a patient with SRC includes elevated serum creatinine, microangiopathic hemolytic anemia (MAHA), thrombocytopenia, and hyperreninemia. Urinalysis commonly shows hematuria, proteinuria, and granular casts visible on microscopy [7, 8, 24, 25].
Although renal biopsies are necessary to confirm the diagnosis and exclude other concurrent pathological processes, they are not regularly requested in SRC [7]. The histological picture of SRC is thrombotic microangiopathy similar to that seen in idiopathic malignant hypertension. Primary small vessel manifestations usually predominate over glomerular changes. Histological findings may vary along the course of the disease [7] (see Table 1).
In some cases, SRC can remain asymptomatic, reflecting an ongoing subclinical renal injury [7]. The acute onset and rapid progression of renal injury could be triggered by high-dose steroids (≥15 mg/day of prednisone), diffuse skin involvement, new-onset anemia, and new cardiac events. Although the use of nonsteroidal anti-inflammatory agents has not been reported as a precipitating factor for SRC, these drugs can induce acute kidney injury (AKI). The reduced synthesis of renal vasodilating prostaglandins (PGE2 and PGI2) and, consequently, compromised renal blood flow can lead to reversible renal ischemia and AKI [25, 26]. Patients who need systemic steroids therapy should be carefully monitored for the development of SRC [8].
In this case, our patient had initially received aggressive fluid resuscitation causing a sudden elevation in her blood pressure. This may have contributed to further deterioration in her kidney function by aggravating more endothelial injury. She had also been managed for MCTD by chronic steroids (prednisone 10 mg/day) and was started on NSAIDS 4 weeks prior to admission. According to Steen [25], cautious use of NSAIDs is prudent in systemic sclerosis patients at high risk for SRC. Therefore, NSAIDs may have also contributed to the precipitation of SRC in our patient.
The treatment of SRC is based on the aggressive control of hypertension with ACEi [9, 10]. The best outcome without reaching dialysis is exhibited when ACEi therapy is given promptly and aggressively. Serum creatinine less than 265 µmol/L (3 mg/dL) at the time of initiation of ACEi is also associated with favourable prognoses [10]. Consequently, ACEi therapy should be started as soon as scleroderma renal crisis is diagnosed [7, 8, 10]. MCTD patients that are experiencing features of scleroderma should be continuously screened for SRC by the regular monitoring of blood pressure and renal functions [8, 10].
To our knowledge, only nine cases of MCTD with SRC have been reported as summarized in Table 1. All patients but one [27] had features of scleroderma, most commonly Raynaud's phenomenon. Of the nine cases gathered, eight cases were treated with ACEi, three of which developed end-stage renal disease requiring chronic hemodialysis [12, 23, 27]. The patient who was not started on ACEi eventually became haemodialysis-dependent [22]. Of the five patients who responded to ACEi, three had sCr levels less than 3 mg/dl at the time of initiation of treatment [6, 23, 28]. This comes in agreement with a previous study conducted by Steen and Medsger that exhibited the best outcomes of ACEi treatment in patients with sCr concentrations less than 3 mg/dl [10].
Several causes might have led to the failure of renal recovery in the patients who received ACEi treatment [12, 23, 27]. Khalil et al. [12] suggest that this outcome in their case was attributed to preexisting chronic kidney disease, previous exposure to high-dose steroids, and delayed initiation of ACEi. Similarly, Khan et al. [23] reported a patient with a two-year history of illness that has been dealt with inadequately resulting in a late diagnosis, the development of advanced chronic kidney disease, and failure of early initiation of therapy with ACEi. Greenberg and Amato [27] reported a case of MCTD with SRC precipitated by high-dose steroids (prednisone 60 mg/day) which did not respond to ACEi treatment. In their report, they explained that corticosteroids inhibit prostacyclin production and the subsequent rise in ACE levels in patients with an underlying microangiopathy involving the kidneys is enough to cause renal failure.
4. Conclusion
Despite the rarity of SRC in MCTD, it should not be overlooked. A sudden rise in blood pressure or the combination of high blood pressure and acute kidney injury (with or without MAHA) in a MCTD patient should be considered SRC-like syndrome until proven otherwise. SRC-like syndrome is a serious complication which, if not treated promptly, might lead to permanent renal damage.
Several reports have emphasized the use of ACEi and its dramatic improvement on the outcomes and survival of scleroderma patients experiencing SRC. However, only a few reports on the treatment of SRC in MCTD exist. Among these reports, including our case, ACEi have shown a major role in the treatment of such crises and the prevention of permanent renal damage. We should consider ACEi a first-line treatment for SRC-like syndrome in MCTD as already documented to be a first-line treatment for SRC in patients with scleroderma. Therefore, in a patient diagnosed with MCTD, we recommend early initiation of treatment with ACEi as soon as SRC is suspected. Future retrospective and prospective studies should be done to further confirm our conclusion.
Acknowledgments
The authors are thankful to their patient who agreed on publishing this case.
Data Availability
Data (laboratory and biopsy results) used to support the findings of this case report are included within the article.
Consent
Written informed consent was obtained from the patient.
Conflicts of Interest
The authors declare that they have no conflicts of interest.
Authors' Contributions
J. Madieh, I. Khamayseh, and K. Gharaibeh searched the literature and drafted the manuscript. A. Hrizat and A. Hamadah revised and edited the paper. All authors reviewed the manuscript. Jomana Madieh and Iman Khamayseh contributed equally to this work.
Figure 1 Serum creatinine trend (blue line) and urine output trend (red line) throughout patient's hospitalization.
Figure 2 Edematous mucoid intimal thickening of interlobular artery (H&E).
Figure 3 Intimal fibrinoid changes in interlobular artery (H&E).
Figure 4 Intimal fibrinoid changes in interlobular artery (trichrome stain). Same interlobular artery is shown in figure 3.
Figure 5 Normal glomeruli (PAS).
Table 1 Summary of case reports of scleroderma renal crisis (SRC) in mixed connective tissue disease (MCTD).
Case report Sex/age Clinical background Pathological features Treatment Outcome
Our case Female/30 History of MCTD presented with vomiting received aggressive fluid resuscitation for suspected dehydration resulting in hypertensive emergency, pulmonary edema, and AKI Biopsy revealed TMA type changes within 3 interlobular arteries. The changes compatible with malignant HTN or SRC. 1st interlobular artery shows moderate edematous mucoid intimal thickening, the 2nd shows intimal fibrinoid change, and the 3rd shows moderate to marked intimal thickening with intimal fibrosis and mild edema Captopril Responded to treatment
Cheta et al. [5] Female/54 Patient presented with shortness of breath, chest pain, Raynaud's phenomenon, and AKI. Diagnosed with a MCTD flare, renal failure, and pneumonia 3/7 intraglomerular thrombi and moderately thickened vessels. Multiple red cell casts within tubular lumina with mild interstitial fibrosis. No evidence of SRC or HUS type TMA Captopril, MMF, plasma exchange, steroid, HD Responded to treatment (Cr 1.7 mg/dL)
Vij et al. [22] Male/21 Oliguria, scleroderma facies, hypertension, and AKI Bloodless glomeruli, thickening of glomerular capillary walls, interlobular vessels fibrointimal hyperplasia with obliteration of capillary lumen, tubular injury, and interstitial edema Plasma exchange, HD HD dependent
Khan et al. [23] Female/36 Hx of Raynaud's phenomenon, blurry vision, arthralgias, and oliguric renal failure 14 glomeruli were seen which showed nonimmune complex-mediated disease process, ischemic collapse with fibrinoid necrosis. Tubules revealed patchy degeneration with interstitial edema and hyaline casts Captopril HD dependent (Cr in range of 2.5–3.0 mg/dl)
Khalil et al. [12] Male/44 Hypertension, dyspnea, vomiting, Raynaud's phenomenon, skin tightening, and AKI. 2/11 sclerosed glomeruli, remaining glomeruli showing mild to severe capillary collapse. Intimal thickening of blood vessel wall. HD, captopril HD dependent (Cr 7.7 mg/dL)
Celikbilek et al. [20] Female/30 History of sausage-like swellings, Raynaud's phenomenon. Renal dysfunction and pulmonary involvement developed following abortion. 7/12 glomeruli with global sclerosis. Interstitial fibrosis and dense mononuclear cell infiltration. Tubular atrophy. Arterial walls with prominent thickening and hyalinization. Enalapril, steroids, CTX. Responded to treatment
Anderson and Vasko [28] Case 1: female/64
Case 2: male/45 Both cases had features of Raynaud's phenomenon and pulmonary HTN. SRC was provoked by steroids in case 1 and by CHF in case 2. Case 2: kidney biopsy at autopsy shows renal interlobular arteries and arterioles with edematous, concentric, myxoid intimal proliferation, and thickening almost totally obliterating lumen in a few vessels. These findings were in accordance with SRC. Enalapril Response to treatment in both cases (Cr12.03,Cr21.35 mg/dL).
Greenberg and Amato [27] Female/64 Inflammatory myopathy and bilateral carpal tunnel syndrome who developed AKI following steroid therapy. Active and severe TMA with extensive mesangiolysis and glomerular capillary wall remodeling with double contours in many glomeruli. Severe arterial and arteriolar sclerosis with fibrin thrombi occlusion. ACEi, HD HD dependent (Cr 7.2 mg/dL)
Satoh et al. [6] Female/47 Raynaud's phenomenon with swollen fingers, sclerodactyly, lymphadenopathy who developed accelerated HTN, AKI and MAHA. 22 glomeruli showed mild ischemic changes. Prominent vascular changes in 2 small arteries, 1/2 with complete occlusion by thrombi and the other with mild intimal proliferation. IF showed faint staining of IgM in the glomerular mesangium. PSL, PGs, ACEi Responded to treatment (Cr 1.0 mg/dL)
MCTD, mixed connective tissue disease; SRC, scleroderma renal crisis; AKI, acute kidney injury, Cr, creatinine; HUS, hemolytic-uremic syndrome; TMA, thrombotic microangiopathy; TTP, thrombotic thrombocytopenic purpura; HTN, hypertension; CHF, congestive heart failure; MAHA, microangiopathic hemolytic anemia; IF, immunofluorescence; HD, hemodialysis; MMF, mycophenolate mofetil; ACEi, angiotensin-converting enzyme inhibitor; CTX, cyclophosphamide; PSL, prednisolone; PGs, prostaglandins. | AZATHIOPRINE, NAPROXEN, NIFEDIPINE, PREDNISONE, SODIUM CHLORIDE | DrugsGivenReaction | CC BY | 33505743 | 19,213,762 | 2021 |
Give an alphabetized list of all active substances of drugs taken by the patient who experienced 'Pulmonary oedema'. | Scleroderma Renal Crisis in a Case of Mixed Connective Tissue Disease Treated Successfully with Angiotensin-Converting Enzyme Inhibitors.
Mixed connective tissue disease (MCTD) is a rheumatic disease syndrome with overlapping features of scleroderma, systemic lupus erythematosus, and polymyositis. An extremely rare but serious complication that can occur in MCTD is scleroderma renal crisis (SRC). There have been different approaches to the treatment of SRC associated with MCTD. We present a case of MCTD with chronic features of Raynaud's phenomenon, dermatomyositis, and thrombocytopenia complicated with acute SRC which showed a great response to ACE inhibitors. Here, we advise the early and aggressive use of ACE inhibitors as soon as SRC is suspected.
1. Introduction
Mixed connective tissue disease (MCTD) is a rheumatic disease syndrome originally described in 1972 and applied to patients with overlapping clinical features of systemic sclerosis (scleroderma), systemic lupus erythematosus (SLE), and polymyositis along with the presence of high titers of a distinctive antibody to the U1 ribonucleoprotein (U1 RNP) [1, 2]. Clinical features of high frequency include Raynaud's phenomenon, arthralgias, swollen hands, fingers with a sausage-like appearance, esophageal dysfunction, and muscle weakness. MCTD can potentially affect various organ systems resulting in pulmonary, renal, cardiovascular, gastrointestinal, and central nervous system manifestations [3, 4]. Scleroderma renal crisis (SRC) is an extremely rare complication in MCTD [5, 6]. It typically presents as an accelerated hypertension of sudden onset and acute renal injury, with or without microangiopathic hemolytic anemia or thrombocytopenia [5, 7, 8]. Several reports have emphasized the use of angiotensin-converting enzyme inhibitors (ACEi) and their dramatic improvement on the outcomes and survival of scleroderma patients experiencing SRC [8–11]. However, only a few reports on the treatment of SRC in MCTD exist [5, 6, 12]. In this article, we report a rare case of MCTD complicated by SRC which was treated successfully with ACEi.
2. Case Report
This is a case of a 30-year-old female with a history of MCTD. She had been diagnosed with MCTD with a positive ANA: >3.5 U (3–5.9 U is positive, ≥6 is strongly positive) and high titers of anti-RNP antibody: 208.8 IU (anti-RNP > 26 U is positive) associated with Raynaud's phenomenon, dermatomyositis, chronic thrombocytopenia, and chronic arthralgia 4 months prior to her presentation. Since then, she was treated with azathioprine, prednisone, nifedipine, and naproxen. The patient was brought to the emergency room (ER) after she had experienced two syncopal episodes. Five days prior to admission, she developed a fever (Tmax: 102 F, 38.8 C) associated with recurrent nausea and vomiting. She also reported dyspnea on exertion, palpitations, and myalgia. Despite negative urinary symptoms, she was diagnosed with a urinary tract infection (UTI) based on the urinalysis (UA) findings of pyuria, hematuria, and +2 proteinuria at that time. She had no diarrhea, abdominal pain, chest pain, or new active skin changes.
Initial physical examination in the ER showed the patient to be alert and oriented. Vital signs showed heart rate (HR) of 110 bpm and blood pressure (BP) of 160/108 mmHg. Based on the clinical picture and laboratory findings, she was thought to be dehydrated and 2 liters of 0.9% saline was given intravenously. Two hours later, she developed sudden tachypnea and dyspnea with hypoxaemia and elevated BP (systolic 220 over diastolic 115) that eventually required intubation for acute hypoxemic respiratory failure. Chest X-ray (CXR) findings were consistent with bilateral pulmonary edema. The patient was placed on nitroglycerine (NG) infusion and transferred to the medical intensive care unit for further management.
Laboratory workup on admission: WBC 8.9 × 10^9/L (4–11 × 10^9), hemoglobin 13.5 g/dl (12–15 g/dL), hematocrit 40.4% (36%–47%), platelet count 165 103/uL (150–400 × 10^9), serum creatinine (sCr) 1.18 mg/dL (baseline sCR was 0.56 mg/dL), serum bicarbonate 17 mmol/L (18–22 mmol/L), plasma renin activity (PRA) 143.5 ng/mL/hour (normal is ≤ 0.6–4.3 ng/mL/hour), potassium 2.3 mmol/L (3.5–5 mmol/L), haptoglobin 11 mg/dL (50–220 mg/dL), C-reactive protein (CRP) 1.9 mg/L (<5 mg/L), ESR 40 mm/hour (normal is < age/2 mm/hour), serum lactate dehydrogenase 423 U/L (50–150 U/L), arterial pH 7.08 (7.35–7.45), arterial pO2 68 mmHg (75–100 mmHg), and arterial HCO3 13.3 mmol/L (18–22 mmHg). Urinalysis showed pyuria, proteinuria, and hematuria including RBC casts and dysmorphic RBCs. The patient was found to be oliguric after monitoring urine output for 24 hours (total urine output was 215 ml). Spot protein/Cr ratio was 3.2.
Despite improvement in BP readings (with an IV antihypertensive medication), the patient remained oliguric and sCr continued to rise, peaking at 1.62 mg/dL, which is 3 times her baseline sCr. Given the history of MCTD along with the typical presentation of a possible SRC-like syndrome, the decision was made to initiate Captopril. Within 24 hours from starting captopril, urine output started to increase and oliguria resolved with improvement in renal function as shown in Figure 1. We titrated up the captopril and were able to wean off nicardipine.
On the third day, once the patient was hemodynamically stable and blood pressure was under control, the decision was made to perform a renal biopsy for further workup. It showed thrombotic microangiopathic changes in the interlobular arteries which are consistent with SRC-like syndrome as seen in Figures 2–5. A day later, the patient was successfully extubated. A week later, the patient was discharged with sCr of 0.88 mg/dL and in good condition with the impression of a SRC-like syndrome in MCTD.
3. Discussion
The exact prevalence and incidence of MCTD remain unknown. However, it has always been reported to be more common in females despite the difference in ratios estimated by different studies [13–15].
Being an overlap syndrome, the definitive diagnosis of MCTD can be difficult to achieve [16]. The early clinical manifestations are nonspecific and the disease state is considered an undifferentiated connective tissue disease (UCTD) [16–18]. During this stage, patients commonly complain of fatigue, myalgias, arthralgias, and Raynaud's phenomenon [16]. Findings suggestive of MCTD occur sequentially evolving over the years [16, 17, 19]. The presence of Raynaud's phenomenon and high titers of anti-U1 RNP antibodies are strong predictors of future evolution to MCTD [16, 19].
As MCTD was initially described in 1972, it was thought to be a connective tissue disease syndrome that is of favourable prognosis and excellent responsiveness to corticosteroid therapy compared to other connective tissue diseases (CTD) [1]. It was suggested that antibodies to ENA (i.e., U1 RNP), which are distinct to MCTD, have a protective role [1]. At that time, renal involvement in MCTD had not yet been identified. However, since then, as more cases of MCTD were being reported, findings of cardiac, pulmonary, and renal involvement emerged and did not have as much of a favourable prognosis as initially perceived.
Multiple criteria (Sharp, Alarcon–Segovia, Khan, Kasukawa) were established for the diagnosis of MCTD based on the serological findings of high-titer-anti-U1 RNP antibodies accompanied by other clinical features of the disease. One study showed that the Alarcon–Segovia's criteria had a sensitivity and specificity of 63% and 86%, respectively [14].
Renal involvement in MCTD is uncommon (10%–26% of patients) and is often asymptomatic [5]. In a study looking at the renal involvement in MCTD, it was found that the only early indicator of renal disease was an abnormal urinalysis with no overt clinical features. Serologic studies were not a helpful predictor either. Renal involvement can occur as glomerulonephritis (GN), nephrotic syndrome, amyloidosis, and, rarely, the renal vasculopathy characteristic of scleroderma, hence the name scleroderma renal crisis (SRC) [12, 20].
SRC in scleroderma occurs in 5–10% of patients [21]. However, in MCTD, it is a severe complication that has rarely been reported [3, 5, 6, 22, 23]. It typically presents as a sudden onset of accelerated hypertension (which could often be malignant) and acute renal injury with or without microangiopathic hemolytic anemia or thrombocytopenia [1, 7, 20].
The biochemical picture of a patient with SRC includes elevated serum creatinine, microangiopathic hemolytic anemia (MAHA), thrombocytopenia, and hyperreninemia. Urinalysis commonly shows hematuria, proteinuria, and granular casts visible on microscopy [7, 8, 24, 25].
Although renal biopsies are necessary to confirm the diagnosis and exclude other concurrent pathological processes, they are not regularly requested in SRC [7]. The histological picture of SRC is thrombotic microangiopathy similar to that seen in idiopathic malignant hypertension. Primary small vessel manifestations usually predominate over glomerular changes. Histological findings may vary along the course of the disease [7] (see Table 1).
In some cases, SRC can remain asymptomatic, reflecting an ongoing subclinical renal injury [7]. The acute onset and rapid progression of renal injury could be triggered by high-dose steroids (≥15 mg/day of prednisone), diffuse skin involvement, new-onset anemia, and new cardiac events. Although the use of nonsteroidal anti-inflammatory agents has not been reported as a precipitating factor for SRC, these drugs can induce acute kidney injury (AKI). The reduced synthesis of renal vasodilating prostaglandins (PGE2 and PGI2) and, consequently, compromised renal blood flow can lead to reversible renal ischemia and AKI [25, 26]. Patients who need systemic steroids therapy should be carefully monitored for the development of SRC [8].
In this case, our patient had initially received aggressive fluid resuscitation causing a sudden elevation in her blood pressure. This may have contributed to further deterioration in her kidney function by aggravating more endothelial injury. She had also been managed for MCTD by chronic steroids (prednisone 10 mg/day) and was started on NSAIDS 4 weeks prior to admission. According to Steen [25], cautious use of NSAIDs is prudent in systemic sclerosis patients at high risk for SRC. Therefore, NSAIDs may have also contributed to the precipitation of SRC in our patient.
The treatment of SRC is based on the aggressive control of hypertension with ACEi [9, 10]. The best outcome without reaching dialysis is exhibited when ACEi therapy is given promptly and aggressively. Serum creatinine less than 265 µmol/L (3 mg/dL) at the time of initiation of ACEi is also associated with favourable prognoses [10]. Consequently, ACEi therapy should be started as soon as scleroderma renal crisis is diagnosed [7, 8, 10]. MCTD patients that are experiencing features of scleroderma should be continuously screened for SRC by the regular monitoring of blood pressure and renal functions [8, 10].
To our knowledge, only nine cases of MCTD with SRC have been reported as summarized in Table 1. All patients but one [27] had features of scleroderma, most commonly Raynaud's phenomenon. Of the nine cases gathered, eight cases were treated with ACEi, three of which developed end-stage renal disease requiring chronic hemodialysis [12, 23, 27]. The patient who was not started on ACEi eventually became haemodialysis-dependent [22]. Of the five patients who responded to ACEi, three had sCr levels less than 3 mg/dl at the time of initiation of treatment [6, 23, 28]. This comes in agreement with a previous study conducted by Steen and Medsger that exhibited the best outcomes of ACEi treatment in patients with sCr concentrations less than 3 mg/dl [10].
Several causes might have led to the failure of renal recovery in the patients who received ACEi treatment [12, 23, 27]. Khalil et al. [12] suggest that this outcome in their case was attributed to preexisting chronic kidney disease, previous exposure to high-dose steroids, and delayed initiation of ACEi. Similarly, Khan et al. [23] reported a patient with a two-year history of illness that has been dealt with inadequately resulting in a late diagnosis, the development of advanced chronic kidney disease, and failure of early initiation of therapy with ACEi. Greenberg and Amato [27] reported a case of MCTD with SRC precipitated by high-dose steroids (prednisone 60 mg/day) which did not respond to ACEi treatment. In their report, they explained that corticosteroids inhibit prostacyclin production and the subsequent rise in ACE levels in patients with an underlying microangiopathy involving the kidneys is enough to cause renal failure.
4. Conclusion
Despite the rarity of SRC in MCTD, it should not be overlooked. A sudden rise in blood pressure or the combination of high blood pressure and acute kidney injury (with or without MAHA) in a MCTD patient should be considered SRC-like syndrome until proven otherwise. SRC-like syndrome is a serious complication which, if not treated promptly, might lead to permanent renal damage.
Several reports have emphasized the use of ACEi and its dramatic improvement on the outcomes and survival of scleroderma patients experiencing SRC. However, only a few reports on the treatment of SRC in MCTD exist. Among these reports, including our case, ACEi have shown a major role in the treatment of such crises and the prevention of permanent renal damage. We should consider ACEi a first-line treatment for SRC-like syndrome in MCTD as already documented to be a first-line treatment for SRC in patients with scleroderma. Therefore, in a patient diagnosed with MCTD, we recommend early initiation of treatment with ACEi as soon as SRC is suspected. Future retrospective and prospective studies should be done to further confirm our conclusion.
Acknowledgments
The authors are thankful to their patient who agreed on publishing this case.
Data Availability
Data (laboratory and biopsy results) used to support the findings of this case report are included within the article.
Consent
Written informed consent was obtained from the patient.
Conflicts of Interest
The authors declare that they have no conflicts of interest.
Authors' Contributions
J. Madieh, I. Khamayseh, and K. Gharaibeh searched the literature and drafted the manuscript. A. Hrizat and A. Hamadah revised and edited the paper. All authors reviewed the manuscript. Jomana Madieh and Iman Khamayseh contributed equally to this work.
Figure 1 Serum creatinine trend (blue line) and urine output trend (red line) throughout patient's hospitalization.
Figure 2 Edematous mucoid intimal thickening of interlobular artery (H&E).
Figure 3 Intimal fibrinoid changes in interlobular artery (H&E).
Figure 4 Intimal fibrinoid changes in interlobular artery (trichrome stain). Same interlobular artery is shown in figure 3.
Figure 5 Normal glomeruli (PAS).
Table 1 Summary of case reports of scleroderma renal crisis (SRC) in mixed connective tissue disease (MCTD).
Case report Sex/age Clinical background Pathological features Treatment Outcome
Our case Female/30 History of MCTD presented with vomiting received aggressive fluid resuscitation for suspected dehydration resulting in hypertensive emergency, pulmonary edema, and AKI Biopsy revealed TMA type changes within 3 interlobular arteries. The changes compatible with malignant HTN or SRC. 1st interlobular artery shows moderate edematous mucoid intimal thickening, the 2nd shows intimal fibrinoid change, and the 3rd shows moderate to marked intimal thickening with intimal fibrosis and mild edema Captopril Responded to treatment
Cheta et al. [5] Female/54 Patient presented with shortness of breath, chest pain, Raynaud's phenomenon, and AKI. Diagnosed with a MCTD flare, renal failure, and pneumonia 3/7 intraglomerular thrombi and moderately thickened vessels. Multiple red cell casts within tubular lumina with mild interstitial fibrosis. No evidence of SRC or HUS type TMA Captopril, MMF, plasma exchange, steroid, HD Responded to treatment (Cr 1.7 mg/dL)
Vij et al. [22] Male/21 Oliguria, scleroderma facies, hypertension, and AKI Bloodless glomeruli, thickening of glomerular capillary walls, interlobular vessels fibrointimal hyperplasia with obliteration of capillary lumen, tubular injury, and interstitial edema Plasma exchange, HD HD dependent
Khan et al. [23] Female/36 Hx of Raynaud's phenomenon, blurry vision, arthralgias, and oliguric renal failure 14 glomeruli were seen which showed nonimmune complex-mediated disease process, ischemic collapse with fibrinoid necrosis. Tubules revealed patchy degeneration with interstitial edema and hyaline casts Captopril HD dependent (Cr in range of 2.5–3.0 mg/dl)
Khalil et al. [12] Male/44 Hypertension, dyspnea, vomiting, Raynaud's phenomenon, skin tightening, and AKI. 2/11 sclerosed glomeruli, remaining glomeruli showing mild to severe capillary collapse. Intimal thickening of blood vessel wall. HD, captopril HD dependent (Cr 7.7 mg/dL)
Celikbilek et al. [20] Female/30 History of sausage-like swellings, Raynaud's phenomenon. Renal dysfunction and pulmonary involvement developed following abortion. 7/12 glomeruli with global sclerosis. Interstitial fibrosis and dense mononuclear cell infiltration. Tubular atrophy. Arterial walls with prominent thickening and hyalinization. Enalapril, steroids, CTX. Responded to treatment
Anderson and Vasko [28] Case 1: female/64
Case 2: male/45 Both cases had features of Raynaud's phenomenon and pulmonary HTN. SRC was provoked by steroids in case 1 and by CHF in case 2. Case 2: kidney biopsy at autopsy shows renal interlobular arteries and arterioles with edematous, concentric, myxoid intimal proliferation, and thickening almost totally obliterating lumen in a few vessels. These findings were in accordance with SRC. Enalapril Response to treatment in both cases (Cr12.03,Cr21.35 mg/dL).
Greenberg and Amato [27] Female/64 Inflammatory myopathy and bilateral carpal tunnel syndrome who developed AKI following steroid therapy. Active and severe TMA with extensive mesangiolysis and glomerular capillary wall remodeling with double contours in many glomeruli. Severe arterial and arteriolar sclerosis with fibrin thrombi occlusion. ACEi, HD HD dependent (Cr 7.2 mg/dL)
Satoh et al. [6] Female/47 Raynaud's phenomenon with swollen fingers, sclerodactyly, lymphadenopathy who developed accelerated HTN, AKI and MAHA. 22 glomeruli showed mild ischemic changes. Prominent vascular changes in 2 small arteries, 1/2 with complete occlusion by thrombi and the other with mild intimal proliferation. IF showed faint staining of IgM in the glomerular mesangium. PSL, PGs, ACEi Responded to treatment (Cr 1.0 mg/dL)
MCTD, mixed connective tissue disease; SRC, scleroderma renal crisis; AKI, acute kidney injury, Cr, creatinine; HUS, hemolytic-uremic syndrome; TMA, thrombotic microangiopathy; TTP, thrombotic thrombocytopenic purpura; HTN, hypertension; CHF, congestive heart failure; MAHA, microangiopathic hemolytic anemia; IF, immunofluorescence; HD, hemodialysis; MMF, mycophenolate mofetil; ACEi, angiotensin-converting enzyme inhibitor; CTX, cyclophosphamide; PSL, prednisolone; PGs, prostaglandins. | AZATHIOPRINE, NAPROXEN, NIFEDIPINE, PREDNISONE, SODIUM CHLORIDE | DrugsGivenReaction | CC BY | 33505743 | 19,213,762 | 2021 |
What was the administration route of drug 'SODIUM CHLORIDE'? | Scleroderma Renal Crisis in a Case of Mixed Connective Tissue Disease Treated Successfully with Angiotensin-Converting Enzyme Inhibitors.
Mixed connective tissue disease (MCTD) is a rheumatic disease syndrome with overlapping features of scleroderma, systemic lupus erythematosus, and polymyositis. An extremely rare but serious complication that can occur in MCTD is scleroderma renal crisis (SRC). There have been different approaches to the treatment of SRC associated with MCTD. We present a case of MCTD with chronic features of Raynaud's phenomenon, dermatomyositis, and thrombocytopenia complicated with acute SRC which showed a great response to ACE inhibitors. Here, we advise the early and aggressive use of ACE inhibitors as soon as SRC is suspected.
1. Introduction
Mixed connective tissue disease (MCTD) is a rheumatic disease syndrome originally described in 1972 and applied to patients with overlapping clinical features of systemic sclerosis (scleroderma), systemic lupus erythematosus (SLE), and polymyositis along with the presence of high titers of a distinctive antibody to the U1 ribonucleoprotein (U1 RNP) [1, 2]. Clinical features of high frequency include Raynaud's phenomenon, arthralgias, swollen hands, fingers with a sausage-like appearance, esophageal dysfunction, and muscle weakness. MCTD can potentially affect various organ systems resulting in pulmonary, renal, cardiovascular, gastrointestinal, and central nervous system manifestations [3, 4]. Scleroderma renal crisis (SRC) is an extremely rare complication in MCTD [5, 6]. It typically presents as an accelerated hypertension of sudden onset and acute renal injury, with or without microangiopathic hemolytic anemia or thrombocytopenia [5, 7, 8]. Several reports have emphasized the use of angiotensin-converting enzyme inhibitors (ACEi) and their dramatic improvement on the outcomes and survival of scleroderma patients experiencing SRC [8–11]. However, only a few reports on the treatment of SRC in MCTD exist [5, 6, 12]. In this article, we report a rare case of MCTD complicated by SRC which was treated successfully with ACEi.
2. Case Report
This is a case of a 30-year-old female with a history of MCTD. She had been diagnosed with MCTD with a positive ANA: >3.5 U (3–5.9 U is positive, ≥6 is strongly positive) and high titers of anti-RNP antibody: 208.8 IU (anti-RNP > 26 U is positive) associated with Raynaud's phenomenon, dermatomyositis, chronic thrombocytopenia, and chronic arthralgia 4 months prior to her presentation. Since then, she was treated with azathioprine, prednisone, nifedipine, and naproxen. The patient was brought to the emergency room (ER) after she had experienced two syncopal episodes. Five days prior to admission, she developed a fever (Tmax: 102 F, 38.8 C) associated with recurrent nausea and vomiting. She also reported dyspnea on exertion, palpitations, and myalgia. Despite negative urinary symptoms, she was diagnosed with a urinary tract infection (UTI) based on the urinalysis (UA) findings of pyuria, hematuria, and +2 proteinuria at that time. She had no diarrhea, abdominal pain, chest pain, or new active skin changes.
Initial physical examination in the ER showed the patient to be alert and oriented. Vital signs showed heart rate (HR) of 110 bpm and blood pressure (BP) of 160/108 mmHg. Based on the clinical picture and laboratory findings, she was thought to be dehydrated and 2 liters of 0.9% saline was given intravenously. Two hours later, she developed sudden tachypnea and dyspnea with hypoxaemia and elevated BP (systolic 220 over diastolic 115) that eventually required intubation for acute hypoxemic respiratory failure. Chest X-ray (CXR) findings were consistent with bilateral pulmonary edema. The patient was placed on nitroglycerine (NG) infusion and transferred to the medical intensive care unit for further management.
Laboratory workup on admission: WBC 8.9 × 10^9/L (4–11 × 10^9), hemoglobin 13.5 g/dl (12–15 g/dL), hematocrit 40.4% (36%–47%), platelet count 165 103/uL (150–400 × 10^9), serum creatinine (sCr) 1.18 mg/dL (baseline sCR was 0.56 mg/dL), serum bicarbonate 17 mmol/L (18–22 mmol/L), plasma renin activity (PRA) 143.5 ng/mL/hour (normal is ≤ 0.6–4.3 ng/mL/hour), potassium 2.3 mmol/L (3.5–5 mmol/L), haptoglobin 11 mg/dL (50–220 mg/dL), C-reactive protein (CRP) 1.9 mg/L (<5 mg/L), ESR 40 mm/hour (normal is < age/2 mm/hour), serum lactate dehydrogenase 423 U/L (50–150 U/L), arterial pH 7.08 (7.35–7.45), arterial pO2 68 mmHg (75–100 mmHg), and arterial HCO3 13.3 mmol/L (18–22 mmHg). Urinalysis showed pyuria, proteinuria, and hematuria including RBC casts and dysmorphic RBCs. The patient was found to be oliguric after monitoring urine output for 24 hours (total urine output was 215 ml). Spot protein/Cr ratio was 3.2.
Despite improvement in BP readings (with an IV antihypertensive medication), the patient remained oliguric and sCr continued to rise, peaking at 1.62 mg/dL, which is 3 times her baseline sCr. Given the history of MCTD along with the typical presentation of a possible SRC-like syndrome, the decision was made to initiate Captopril. Within 24 hours from starting captopril, urine output started to increase and oliguria resolved with improvement in renal function as shown in Figure 1. We titrated up the captopril and were able to wean off nicardipine.
On the third day, once the patient was hemodynamically stable and blood pressure was under control, the decision was made to perform a renal biopsy for further workup. It showed thrombotic microangiopathic changes in the interlobular arteries which are consistent with SRC-like syndrome as seen in Figures 2–5. A day later, the patient was successfully extubated. A week later, the patient was discharged with sCr of 0.88 mg/dL and in good condition with the impression of a SRC-like syndrome in MCTD.
3. Discussion
The exact prevalence and incidence of MCTD remain unknown. However, it has always been reported to be more common in females despite the difference in ratios estimated by different studies [13–15].
Being an overlap syndrome, the definitive diagnosis of MCTD can be difficult to achieve [16]. The early clinical manifestations are nonspecific and the disease state is considered an undifferentiated connective tissue disease (UCTD) [16–18]. During this stage, patients commonly complain of fatigue, myalgias, arthralgias, and Raynaud's phenomenon [16]. Findings suggestive of MCTD occur sequentially evolving over the years [16, 17, 19]. The presence of Raynaud's phenomenon and high titers of anti-U1 RNP antibodies are strong predictors of future evolution to MCTD [16, 19].
As MCTD was initially described in 1972, it was thought to be a connective tissue disease syndrome that is of favourable prognosis and excellent responsiveness to corticosteroid therapy compared to other connective tissue diseases (CTD) [1]. It was suggested that antibodies to ENA (i.e., U1 RNP), which are distinct to MCTD, have a protective role [1]. At that time, renal involvement in MCTD had not yet been identified. However, since then, as more cases of MCTD were being reported, findings of cardiac, pulmonary, and renal involvement emerged and did not have as much of a favourable prognosis as initially perceived.
Multiple criteria (Sharp, Alarcon–Segovia, Khan, Kasukawa) were established for the diagnosis of MCTD based on the serological findings of high-titer-anti-U1 RNP antibodies accompanied by other clinical features of the disease. One study showed that the Alarcon–Segovia's criteria had a sensitivity and specificity of 63% and 86%, respectively [14].
Renal involvement in MCTD is uncommon (10%–26% of patients) and is often asymptomatic [5]. In a study looking at the renal involvement in MCTD, it was found that the only early indicator of renal disease was an abnormal urinalysis with no overt clinical features. Serologic studies were not a helpful predictor either. Renal involvement can occur as glomerulonephritis (GN), nephrotic syndrome, amyloidosis, and, rarely, the renal vasculopathy characteristic of scleroderma, hence the name scleroderma renal crisis (SRC) [12, 20].
SRC in scleroderma occurs in 5–10% of patients [21]. However, in MCTD, it is a severe complication that has rarely been reported [3, 5, 6, 22, 23]. It typically presents as a sudden onset of accelerated hypertension (which could often be malignant) and acute renal injury with or without microangiopathic hemolytic anemia or thrombocytopenia [1, 7, 20].
The biochemical picture of a patient with SRC includes elevated serum creatinine, microangiopathic hemolytic anemia (MAHA), thrombocytopenia, and hyperreninemia. Urinalysis commonly shows hematuria, proteinuria, and granular casts visible on microscopy [7, 8, 24, 25].
Although renal biopsies are necessary to confirm the diagnosis and exclude other concurrent pathological processes, they are not regularly requested in SRC [7]. The histological picture of SRC is thrombotic microangiopathy similar to that seen in idiopathic malignant hypertension. Primary small vessel manifestations usually predominate over glomerular changes. Histological findings may vary along the course of the disease [7] (see Table 1).
In some cases, SRC can remain asymptomatic, reflecting an ongoing subclinical renal injury [7]. The acute onset and rapid progression of renal injury could be triggered by high-dose steroids (≥15 mg/day of prednisone), diffuse skin involvement, new-onset anemia, and new cardiac events. Although the use of nonsteroidal anti-inflammatory agents has not been reported as a precipitating factor for SRC, these drugs can induce acute kidney injury (AKI). The reduced synthesis of renal vasodilating prostaglandins (PGE2 and PGI2) and, consequently, compromised renal blood flow can lead to reversible renal ischemia and AKI [25, 26]. Patients who need systemic steroids therapy should be carefully monitored for the development of SRC [8].
In this case, our patient had initially received aggressive fluid resuscitation causing a sudden elevation in her blood pressure. This may have contributed to further deterioration in her kidney function by aggravating more endothelial injury. She had also been managed for MCTD by chronic steroids (prednisone 10 mg/day) and was started on NSAIDS 4 weeks prior to admission. According to Steen [25], cautious use of NSAIDs is prudent in systemic sclerosis patients at high risk for SRC. Therefore, NSAIDs may have also contributed to the precipitation of SRC in our patient.
The treatment of SRC is based on the aggressive control of hypertension with ACEi [9, 10]. The best outcome without reaching dialysis is exhibited when ACEi therapy is given promptly and aggressively. Serum creatinine less than 265 µmol/L (3 mg/dL) at the time of initiation of ACEi is also associated with favourable prognoses [10]. Consequently, ACEi therapy should be started as soon as scleroderma renal crisis is diagnosed [7, 8, 10]. MCTD patients that are experiencing features of scleroderma should be continuously screened for SRC by the regular monitoring of blood pressure and renal functions [8, 10].
To our knowledge, only nine cases of MCTD with SRC have been reported as summarized in Table 1. All patients but one [27] had features of scleroderma, most commonly Raynaud's phenomenon. Of the nine cases gathered, eight cases were treated with ACEi, three of which developed end-stage renal disease requiring chronic hemodialysis [12, 23, 27]. The patient who was not started on ACEi eventually became haemodialysis-dependent [22]. Of the five patients who responded to ACEi, three had sCr levels less than 3 mg/dl at the time of initiation of treatment [6, 23, 28]. This comes in agreement with a previous study conducted by Steen and Medsger that exhibited the best outcomes of ACEi treatment in patients with sCr concentrations less than 3 mg/dl [10].
Several causes might have led to the failure of renal recovery in the patients who received ACEi treatment [12, 23, 27]. Khalil et al. [12] suggest that this outcome in their case was attributed to preexisting chronic kidney disease, previous exposure to high-dose steroids, and delayed initiation of ACEi. Similarly, Khan et al. [23] reported a patient with a two-year history of illness that has been dealt with inadequately resulting in a late diagnosis, the development of advanced chronic kidney disease, and failure of early initiation of therapy with ACEi. Greenberg and Amato [27] reported a case of MCTD with SRC precipitated by high-dose steroids (prednisone 60 mg/day) which did not respond to ACEi treatment. In their report, they explained that corticosteroids inhibit prostacyclin production and the subsequent rise in ACE levels in patients with an underlying microangiopathy involving the kidneys is enough to cause renal failure.
4. Conclusion
Despite the rarity of SRC in MCTD, it should not be overlooked. A sudden rise in blood pressure or the combination of high blood pressure and acute kidney injury (with or without MAHA) in a MCTD patient should be considered SRC-like syndrome until proven otherwise. SRC-like syndrome is a serious complication which, if not treated promptly, might lead to permanent renal damage.
Several reports have emphasized the use of ACEi and its dramatic improvement on the outcomes and survival of scleroderma patients experiencing SRC. However, only a few reports on the treatment of SRC in MCTD exist. Among these reports, including our case, ACEi have shown a major role in the treatment of such crises and the prevention of permanent renal damage. We should consider ACEi a first-line treatment for SRC-like syndrome in MCTD as already documented to be a first-line treatment for SRC in patients with scleroderma. Therefore, in a patient diagnosed with MCTD, we recommend early initiation of treatment with ACEi as soon as SRC is suspected. Future retrospective and prospective studies should be done to further confirm our conclusion.
Acknowledgments
The authors are thankful to their patient who agreed on publishing this case.
Data Availability
Data (laboratory and biopsy results) used to support the findings of this case report are included within the article.
Consent
Written informed consent was obtained from the patient.
Conflicts of Interest
The authors declare that they have no conflicts of interest.
Authors' Contributions
J. Madieh, I. Khamayseh, and K. Gharaibeh searched the literature and drafted the manuscript. A. Hrizat and A. Hamadah revised and edited the paper. All authors reviewed the manuscript. Jomana Madieh and Iman Khamayseh contributed equally to this work.
Figure 1 Serum creatinine trend (blue line) and urine output trend (red line) throughout patient's hospitalization.
Figure 2 Edematous mucoid intimal thickening of interlobular artery (H&E).
Figure 3 Intimal fibrinoid changes in interlobular artery (H&E).
Figure 4 Intimal fibrinoid changes in interlobular artery (trichrome stain). Same interlobular artery is shown in figure 3.
Figure 5 Normal glomeruli (PAS).
Table 1 Summary of case reports of scleroderma renal crisis (SRC) in mixed connective tissue disease (MCTD).
Case report Sex/age Clinical background Pathological features Treatment Outcome
Our case Female/30 History of MCTD presented with vomiting received aggressive fluid resuscitation for suspected dehydration resulting in hypertensive emergency, pulmonary edema, and AKI Biopsy revealed TMA type changes within 3 interlobular arteries. The changes compatible with malignant HTN or SRC. 1st interlobular artery shows moderate edematous mucoid intimal thickening, the 2nd shows intimal fibrinoid change, and the 3rd shows moderate to marked intimal thickening with intimal fibrosis and mild edema Captopril Responded to treatment
Cheta et al. [5] Female/54 Patient presented with shortness of breath, chest pain, Raynaud's phenomenon, and AKI. Diagnosed with a MCTD flare, renal failure, and pneumonia 3/7 intraglomerular thrombi and moderately thickened vessels. Multiple red cell casts within tubular lumina with mild interstitial fibrosis. No evidence of SRC or HUS type TMA Captopril, MMF, plasma exchange, steroid, HD Responded to treatment (Cr 1.7 mg/dL)
Vij et al. [22] Male/21 Oliguria, scleroderma facies, hypertension, and AKI Bloodless glomeruli, thickening of glomerular capillary walls, interlobular vessels fibrointimal hyperplasia with obliteration of capillary lumen, tubular injury, and interstitial edema Plasma exchange, HD HD dependent
Khan et al. [23] Female/36 Hx of Raynaud's phenomenon, blurry vision, arthralgias, and oliguric renal failure 14 glomeruli were seen which showed nonimmune complex-mediated disease process, ischemic collapse with fibrinoid necrosis. Tubules revealed patchy degeneration with interstitial edema and hyaline casts Captopril HD dependent (Cr in range of 2.5–3.0 mg/dl)
Khalil et al. [12] Male/44 Hypertension, dyspnea, vomiting, Raynaud's phenomenon, skin tightening, and AKI. 2/11 sclerosed glomeruli, remaining glomeruli showing mild to severe capillary collapse. Intimal thickening of blood vessel wall. HD, captopril HD dependent (Cr 7.7 mg/dL)
Celikbilek et al. [20] Female/30 History of sausage-like swellings, Raynaud's phenomenon. Renal dysfunction and pulmonary involvement developed following abortion. 7/12 glomeruli with global sclerosis. Interstitial fibrosis and dense mononuclear cell infiltration. Tubular atrophy. Arterial walls with prominent thickening and hyalinization. Enalapril, steroids, CTX. Responded to treatment
Anderson and Vasko [28] Case 1: female/64
Case 2: male/45 Both cases had features of Raynaud's phenomenon and pulmonary HTN. SRC was provoked by steroids in case 1 and by CHF in case 2. Case 2: kidney biopsy at autopsy shows renal interlobular arteries and arterioles with edematous, concentric, myxoid intimal proliferation, and thickening almost totally obliterating lumen in a few vessels. These findings were in accordance with SRC. Enalapril Response to treatment in both cases (Cr12.03,Cr21.35 mg/dL).
Greenberg and Amato [27] Female/64 Inflammatory myopathy and bilateral carpal tunnel syndrome who developed AKI following steroid therapy. Active and severe TMA with extensive mesangiolysis and glomerular capillary wall remodeling with double contours in many glomeruli. Severe arterial and arteriolar sclerosis with fibrin thrombi occlusion. ACEi, HD HD dependent (Cr 7.2 mg/dL)
Satoh et al. [6] Female/47 Raynaud's phenomenon with swollen fingers, sclerodactyly, lymphadenopathy who developed accelerated HTN, AKI and MAHA. 22 glomeruli showed mild ischemic changes. Prominent vascular changes in 2 small arteries, 1/2 with complete occlusion by thrombi and the other with mild intimal proliferation. IF showed faint staining of IgM in the glomerular mesangium. PSL, PGs, ACEi Responded to treatment (Cr 1.0 mg/dL)
MCTD, mixed connective tissue disease; SRC, scleroderma renal crisis; AKI, acute kidney injury, Cr, creatinine; HUS, hemolytic-uremic syndrome; TMA, thrombotic microangiopathy; TTP, thrombotic thrombocytopenic purpura; HTN, hypertension; CHF, congestive heart failure; MAHA, microangiopathic hemolytic anemia; IF, immunofluorescence; HD, hemodialysis; MMF, mycophenolate mofetil; ACEi, angiotensin-converting enzyme inhibitor; CTX, cyclophosphamide; PSL, prednisolone; PGs, prostaglandins. | Intravenous (not otherwise specified) | DrugAdministrationRoute | CC BY | 33505743 | 19,213,762 | 2021 |
What was the outcome of reaction 'Hypertensive emergency'? | Scleroderma Renal Crisis in a Case of Mixed Connective Tissue Disease Treated Successfully with Angiotensin-Converting Enzyme Inhibitors.
Mixed connective tissue disease (MCTD) is a rheumatic disease syndrome with overlapping features of scleroderma, systemic lupus erythematosus, and polymyositis. An extremely rare but serious complication that can occur in MCTD is scleroderma renal crisis (SRC). There have been different approaches to the treatment of SRC associated with MCTD. We present a case of MCTD with chronic features of Raynaud's phenomenon, dermatomyositis, and thrombocytopenia complicated with acute SRC which showed a great response to ACE inhibitors. Here, we advise the early and aggressive use of ACE inhibitors as soon as SRC is suspected.
1. Introduction
Mixed connective tissue disease (MCTD) is a rheumatic disease syndrome originally described in 1972 and applied to patients with overlapping clinical features of systemic sclerosis (scleroderma), systemic lupus erythematosus (SLE), and polymyositis along with the presence of high titers of a distinctive antibody to the U1 ribonucleoprotein (U1 RNP) [1, 2]. Clinical features of high frequency include Raynaud's phenomenon, arthralgias, swollen hands, fingers with a sausage-like appearance, esophageal dysfunction, and muscle weakness. MCTD can potentially affect various organ systems resulting in pulmonary, renal, cardiovascular, gastrointestinal, and central nervous system manifestations [3, 4]. Scleroderma renal crisis (SRC) is an extremely rare complication in MCTD [5, 6]. It typically presents as an accelerated hypertension of sudden onset and acute renal injury, with or without microangiopathic hemolytic anemia or thrombocytopenia [5, 7, 8]. Several reports have emphasized the use of angiotensin-converting enzyme inhibitors (ACEi) and their dramatic improvement on the outcomes and survival of scleroderma patients experiencing SRC [8–11]. However, only a few reports on the treatment of SRC in MCTD exist [5, 6, 12]. In this article, we report a rare case of MCTD complicated by SRC which was treated successfully with ACEi.
2. Case Report
This is a case of a 30-year-old female with a history of MCTD. She had been diagnosed with MCTD with a positive ANA: >3.5 U (3–5.9 U is positive, ≥6 is strongly positive) and high titers of anti-RNP antibody: 208.8 IU (anti-RNP > 26 U is positive) associated with Raynaud's phenomenon, dermatomyositis, chronic thrombocytopenia, and chronic arthralgia 4 months prior to her presentation. Since then, she was treated with azathioprine, prednisone, nifedipine, and naproxen. The patient was brought to the emergency room (ER) after she had experienced two syncopal episodes. Five days prior to admission, she developed a fever (Tmax: 102 F, 38.8 C) associated with recurrent nausea and vomiting. She also reported dyspnea on exertion, palpitations, and myalgia. Despite negative urinary symptoms, she was diagnosed with a urinary tract infection (UTI) based on the urinalysis (UA) findings of pyuria, hematuria, and +2 proteinuria at that time. She had no diarrhea, abdominal pain, chest pain, or new active skin changes.
Initial physical examination in the ER showed the patient to be alert and oriented. Vital signs showed heart rate (HR) of 110 bpm and blood pressure (BP) of 160/108 mmHg. Based on the clinical picture and laboratory findings, she was thought to be dehydrated and 2 liters of 0.9% saline was given intravenously. Two hours later, she developed sudden tachypnea and dyspnea with hypoxaemia and elevated BP (systolic 220 over diastolic 115) that eventually required intubation for acute hypoxemic respiratory failure. Chest X-ray (CXR) findings were consistent with bilateral pulmonary edema. The patient was placed on nitroglycerine (NG) infusion and transferred to the medical intensive care unit for further management.
Laboratory workup on admission: WBC 8.9 × 10^9/L (4–11 × 10^9), hemoglobin 13.5 g/dl (12–15 g/dL), hematocrit 40.4% (36%–47%), platelet count 165 103/uL (150–400 × 10^9), serum creatinine (sCr) 1.18 mg/dL (baseline sCR was 0.56 mg/dL), serum bicarbonate 17 mmol/L (18–22 mmol/L), plasma renin activity (PRA) 143.5 ng/mL/hour (normal is ≤ 0.6–4.3 ng/mL/hour), potassium 2.3 mmol/L (3.5–5 mmol/L), haptoglobin 11 mg/dL (50–220 mg/dL), C-reactive protein (CRP) 1.9 mg/L (<5 mg/L), ESR 40 mm/hour (normal is < age/2 mm/hour), serum lactate dehydrogenase 423 U/L (50–150 U/L), arterial pH 7.08 (7.35–7.45), arterial pO2 68 mmHg (75–100 mmHg), and arterial HCO3 13.3 mmol/L (18–22 mmHg). Urinalysis showed pyuria, proteinuria, and hematuria including RBC casts and dysmorphic RBCs. The patient was found to be oliguric after monitoring urine output for 24 hours (total urine output was 215 ml). Spot protein/Cr ratio was 3.2.
Despite improvement in BP readings (with an IV antihypertensive medication), the patient remained oliguric and sCr continued to rise, peaking at 1.62 mg/dL, which is 3 times her baseline sCr. Given the history of MCTD along with the typical presentation of a possible SRC-like syndrome, the decision was made to initiate Captopril. Within 24 hours from starting captopril, urine output started to increase and oliguria resolved with improvement in renal function as shown in Figure 1. We titrated up the captopril and were able to wean off nicardipine.
On the third day, once the patient was hemodynamically stable and blood pressure was under control, the decision was made to perform a renal biopsy for further workup. It showed thrombotic microangiopathic changes in the interlobular arteries which are consistent with SRC-like syndrome as seen in Figures 2–5. A day later, the patient was successfully extubated. A week later, the patient was discharged with sCr of 0.88 mg/dL and in good condition with the impression of a SRC-like syndrome in MCTD.
3. Discussion
The exact prevalence and incidence of MCTD remain unknown. However, it has always been reported to be more common in females despite the difference in ratios estimated by different studies [13–15].
Being an overlap syndrome, the definitive diagnosis of MCTD can be difficult to achieve [16]. The early clinical manifestations are nonspecific and the disease state is considered an undifferentiated connective tissue disease (UCTD) [16–18]. During this stage, patients commonly complain of fatigue, myalgias, arthralgias, and Raynaud's phenomenon [16]. Findings suggestive of MCTD occur sequentially evolving over the years [16, 17, 19]. The presence of Raynaud's phenomenon and high titers of anti-U1 RNP antibodies are strong predictors of future evolution to MCTD [16, 19].
As MCTD was initially described in 1972, it was thought to be a connective tissue disease syndrome that is of favourable prognosis and excellent responsiveness to corticosteroid therapy compared to other connective tissue diseases (CTD) [1]. It was suggested that antibodies to ENA (i.e., U1 RNP), which are distinct to MCTD, have a protective role [1]. At that time, renal involvement in MCTD had not yet been identified. However, since then, as more cases of MCTD were being reported, findings of cardiac, pulmonary, and renal involvement emerged and did not have as much of a favourable prognosis as initially perceived.
Multiple criteria (Sharp, Alarcon–Segovia, Khan, Kasukawa) were established for the diagnosis of MCTD based on the serological findings of high-titer-anti-U1 RNP antibodies accompanied by other clinical features of the disease. One study showed that the Alarcon–Segovia's criteria had a sensitivity and specificity of 63% and 86%, respectively [14].
Renal involvement in MCTD is uncommon (10%–26% of patients) and is often asymptomatic [5]. In a study looking at the renal involvement in MCTD, it was found that the only early indicator of renal disease was an abnormal urinalysis with no overt clinical features. Serologic studies were not a helpful predictor either. Renal involvement can occur as glomerulonephritis (GN), nephrotic syndrome, amyloidosis, and, rarely, the renal vasculopathy characteristic of scleroderma, hence the name scleroderma renal crisis (SRC) [12, 20].
SRC in scleroderma occurs in 5–10% of patients [21]. However, in MCTD, it is a severe complication that has rarely been reported [3, 5, 6, 22, 23]. It typically presents as a sudden onset of accelerated hypertension (which could often be malignant) and acute renal injury with or without microangiopathic hemolytic anemia or thrombocytopenia [1, 7, 20].
The biochemical picture of a patient with SRC includes elevated serum creatinine, microangiopathic hemolytic anemia (MAHA), thrombocytopenia, and hyperreninemia. Urinalysis commonly shows hematuria, proteinuria, and granular casts visible on microscopy [7, 8, 24, 25].
Although renal biopsies are necessary to confirm the diagnosis and exclude other concurrent pathological processes, they are not regularly requested in SRC [7]. The histological picture of SRC is thrombotic microangiopathy similar to that seen in idiopathic malignant hypertension. Primary small vessel manifestations usually predominate over glomerular changes. Histological findings may vary along the course of the disease [7] (see Table 1).
In some cases, SRC can remain asymptomatic, reflecting an ongoing subclinical renal injury [7]. The acute onset and rapid progression of renal injury could be triggered by high-dose steroids (≥15 mg/day of prednisone), diffuse skin involvement, new-onset anemia, and new cardiac events. Although the use of nonsteroidal anti-inflammatory agents has not been reported as a precipitating factor for SRC, these drugs can induce acute kidney injury (AKI). The reduced synthesis of renal vasodilating prostaglandins (PGE2 and PGI2) and, consequently, compromised renal blood flow can lead to reversible renal ischemia and AKI [25, 26]. Patients who need systemic steroids therapy should be carefully monitored for the development of SRC [8].
In this case, our patient had initially received aggressive fluid resuscitation causing a sudden elevation in her blood pressure. This may have contributed to further deterioration in her kidney function by aggravating more endothelial injury. She had also been managed for MCTD by chronic steroids (prednisone 10 mg/day) and was started on NSAIDS 4 weeks prior to admission. According to Steen [25], cautious use of NSAIDs is prudent in systemic sclerosis patients at high risk for SRC. Therefore, NSAIDs may have also contributed to the precipitation of SRC in our patient.
The treatment of SRC is based on the aggressive control of hypertension with ACEi [9, 10]. The best outcome without reaching dialysis is exhibited when ACEi therapy is given promptly and aggressively. Serum creatinine less than 265 µmol/L (3 mg/dL) at the time of initiation of ACEi is also associated with favourable prognoses [10]. Consequently, ACEi therapy should be started as soon as scleroderma renal crisis is diagnosed [7, 8, 10]. MCTD patients that are experiencing features of scleroderma should be continuously screened for SRC by the regular monitoring of blood pressure and renal functions [8, 10].
To our knowledge, only nine cases of MCTD with SRC have been reported as summarized in Table 1. All patients but one [27] had features of scleroderma, most commonly Raynaud's phenomenon. Of the nine cases gathered, eight cases were treated with ACEi, three of which developed end-stage renal disease requiring chronic hemodialysis [12, 23, 27]. The patient who was not started on ACEi eventually became haemodialysis-dependent [22]. Of the five patients who responded to ACEi, three had sCr levels less than 3 mg/dl at the time of initiation of treatment [6, 23, 28]. This comes in agreement with a previous study conducted by Steen and Medsger that exhibited the best outcomes of ACEi treatment in patients with sCr concentrations less than 3 mg/dl [10].
Several causes might have led to the failure of renal recovery in the patients who received ACEi treatment [12, 23, 27]. Khalil et al. [12] suggest that this outcome in their case was attributed to preexisting chronic kidney disease, previous exposure to high-dose steroids, and delayed initiation of ACEi. Similarly, Khan et al. [23] reported a patient with a two-year history of illness that has been dealt with inadequately resulting in a late diagnosis, the development of advanced chronic kidney disease, and failure of early initiation of therapy with ACEi. Greenberg and Amato [27] reported a case of MCTD with SRC precipitated by high-dose steroids (prednisone 60 mg/day) which did not respond to ACEi treatment. In their report, they explained that corticosteroids inhibit prostacyclin production and the subsequent rise in ACE levels in patients with an underlying microangiopathy involving the kidneys is enough to cause renal failure.
4. Conclusion
Despite the rarity of SRC in MCTD, it should not be overlooked. A sudden rise in blood pressure or the combination of high blood pressure and acute kidney injury (with or without MAHA) in a MCTD patient should be considered SRC-like syndrome until proven otherwise. SRC-like syndrome is a serious complication which, if not treated promptly, might lead to permanent renal damage.
Several reports have emphasized the use of ACEi and its dramatic improvement on the outcomes and survival of scleroderma patients experiencing SRC. However, only a few reports on the treatment of SRC in MCTD exist. Among these reports, including our case, ACEi have shown a major role in the treatment of such crises and the prevention of permanent renal damage. We should consider ACEi a first-line treatment for SRC-like syndrome in MCTD as already documented to be a first-line treatment for SRC in patients with scleroderma. Therefore, in a patient diagnosed with MCTD, we recommend early initiation of treatment with ACEi as soon as SRC is suspected. Future retrospective and prospective studies should be done to further confirm our conclusion.
Acknowledgments
The authors are thankful to their patient who agreed on publishing this case.
Data Availability
Data (laboratory and biopsy results) used to support the findings of this case report are included within the article.
Consent
Written informed consent was obtained from the patient.
Conflicts of Interest
The authors declare that they have no conflicts of interest.
Authors' Contributions
J. Madieh, I. Khamayseh, and K. Gharaibeh searched the literature and drafted the manuscript. A. Hrizat and A. Hamadah revised and edited the paper. All authors reviewed the manuscript. Jomana Madieh and Iman Khamayseh contributed equally to this work.
Figure 1 Serum creatinine trend (blue line) and urine output trend (red line) throughout patient's hospitalization.
Figure 2 Edematous mucoid intimal thickening of interlobular artery (H&E).
Figure 3 Intimal fibrinoid changes in interlobular artery (H&E).
Figure 4 Intimal fibrinoid changes in interlobular artery (trichrome stain). Same interlobular artery is shown in figure 3.
Figure 5 Normal glomeruli (PAS).
Table 1 Summary of case reports of scleroderma renal crisis (SRC) in mixed connective tissue disease (MCTD).
Case report Sex/age Clinical background Pathological features Treatment Outcome
Our case Female/30 History of MCTD presented with vomiting received aggressive fluid resuscitation for suspected dehydration resulting in hypertensive emergency, pulmonary edema, and AKI Biopsy revealed TMA type changes within 3 interlobular arteries. The changes compatible with malignant HTN or SRC. 1st interlobular artery shows moderate edematous mucoid intimal thickening, the 2nd shows intimal fibrinoid change, and the 3rd shows moderate to marked intimal thickening with intimal fibrosis and mild edema Captopril Responded to treatment
Cheta et al. [5] Female/54 Patient presented with shortness of breath, chest pain, Raynaud's phenomenon, and AKI. Diagnosed with a MCTD flare, renal failure, and pneumonia 3/7 intraglomerular thrombi and moderately thickened vessels. Multiple red cell casts within tubular lumina with mild interstitial fibrosis. No evidence of SRC or HUS type TMA Captopril, MMF, plasma exchange, steroid, HD Responded to treatment (Cr 1.7 mg/dL)
Vij et al. [22] Male/21 Oliguria, scleroderma facies, hypertension, and AKI Bloodless glomeruli, thickening of glomerular capillary walls, interlobular vessels fibrointimal hyperplasia with obliteration of capillary lumen, tubular injury, and interstitial edema Plasma exchange, HD HD dependent
Khan et al. [23] Female/36 Hx of Raynaud's phenomenon, blurry vision, arthralgias, and oliguric renal failure 14 glomeruli were seen which showed nonimmune complex-mediated disease process, ischemic collapse with fibrinoid necrosis. Tubules revealed patchy degeneration with interstitial edema and hyaline casts Captopril HD dependent (Cr in range of 2.5–3.0 mg/dl)
Khalil et al. [12] Male/44 Hypertension, dyspnea, vomiting, Raynaud's phenomenon, skin tightening, and AKI. 2/11 sclerosed glomeruli, remaining glomeruli showing mild to severe capillary collapse. Intimal thickening of blood vessel wall. HD, captopril HD dependent (Cr 7.7 mg/dL)
Celikbilek et al. [20] Female/30 History of sausage-like swellings, Raynaud's phenomenon. Renal dysfunction and pulmonary involvement developed following abortion. 7/12 glomeruli with global sclerosis. Interstitial fibrosis and dense mononuclear cell infiltration. Tubular atrophy. Arterial walls with prominent thickening and hyalinization. Enalapril, steroids, CTX. Responded to treatment
Anderson and Vasko [28] Case 1: female/64
Case 2: male/45 Both cases had features of Raynaud's phenomenon and pulmonary HTN. SRC was provoked by steroids in case 1 and by CHF in case 2. Case 2: kidney biopsy at autopsy shows renal interlobular arteries and arterioles with edematous, concentric, myxoid intimal proliferation, and thickening almost totally obliterating lumen in a few vessels. These findings were in accordance with SRC. Enalapril Response to treatment in both cases (Cr12.03,Cr21.35 mg/dL).
Greenberg and Amato [27] Female/64 Inflammatory myopathy and bilateral carpal tunnel syndrome who developed AKI following steroid therapy. Active and severe TMA with extensive mesangiolysis and glomerular capillary wall remodeling with double contours in many glomeruli. Severe arterial and arteriolar sclerosis with fibrin thrombi occlusion. ACEi, HD HD dependent (Cr 7.2 mg/dL)
Satoh et al. [6] Female/47 Raynaud's phenomenon with swollen fingers, sclerodactyly, lymphadenopathy who developed accelerated HTN, AKI and MAHA. 22 glomeruli showed mild ischemic changes. Prominent vascular changes in 2 small arteries, 1/2 with complete occlusion by thrombi and the other with mild intimal proliferation. IF showed faint staining of IgM in the glomerular mesangium. PSL, PGs, ACEi Responded to treatment (Cr 1.0 mg/dL)
MCTD, mixed connective tissue disease; SRC, scleroderma renal crisis; AKI, acute kidney injury, Cr, creatinine; HUS, hemolytic-uremic syndrome; TMA, thrombotic microangiopathy; TTP, thrombotic thrombocytopenic purpura; HTN, hypertension; CHF, congestive heart failure; MAHA, microangiopathic hemolytic anemia; IF, immunofluorescence; HD, hemodialysis; MMF, mycophenolate mofetil; ACEi, angiotensin-converting enzyme inhibitor; CTX, cyclophosphamide; PSL, prednisolone; PGs, prostaglandins. | Recovered | ReactionOutcome | CC BY | 33505743 | 19,213,762 | 2021 |
Give an alphabetized list of all active substances of drugs taken by the patient who experienced 'Respiratory tract infection'. | Asymptomatic Lymphocytic Interstitial Pneumonia with Extensive HRCT Changes Preceding Sjogren's Syndrome.
Lymphocytic interstitial pneumonia (LIP) is a rare condition, commonly associated with Sjogren's syndrome (SS). We report a 53-year-old woman with an incidental finding of an abnormal chest radiograph. LIP was diagnosed based on high-resolution computed tomography and lung biopsy, but treatment was not initiated. Six years later, she developed cough and dyspnoea, associated with dry eyes, dry mouth, and arthralgia. While being investigated for the respiratory symptoms, she developed cutaneous vasculitis and was treated with 1 mg/kg prednisolone, which resulted in the improvement of her respiratory symptoms. Physical examination revealed fine bibasal crepitations, active vasculitic skin lesions, and a positive Schirmer's test. Investigations revealed a restrictive pattern in the pulmonary function test, stable LIP pattern in HRCT, and positive anti-Ro antibodies. She was treated with prednisolone and azathioprine for 18 months, and within this time, she was hospitalised for flare of LIP, as well as respiratory tract infection on three occasions. During the third flare, when she also developed cutaneous vasculitis, she agreed for prednisolone but refused other second-line agents. To date, she remained well with the maintenance of prednisolone 2.5 mg monotherapy for more than one year. The lessons from this case are (i) patients with LIP can be asymptomatic, (ii) LIP can precede symptoms of SS, and (iii) treatment decision for asymptomatic patients with abnormal imaging or patients with mild severity should be weighed between the risk of immunosuppression and risk of active disease.
1. Introduction
Lymphocytic interstitial pneumonia (LIP) is a rare condition. Cha et al. reported that among 1,167 lung biopsies of patients with interstitial lung disease (ILD) collected over 14 years, only 15 were found to have LIP [1]. LIP is regarded as both a disease (rare idiopathic interstitial pneumonia) and as a nonneoplastic, inflammatory pulmonary reaction to various external stimuli or systemic disease [1]. It is commonly found in connective tissue disease (CTD) especially Sjogren's syndrome (SS). A systematic review of pulmonary involvement in SS reported that of 146 histopathological diagnoses, the most common was nonspecific interstitial pneumonia (45%), followed by bronchiolitis (25%), usual interstitial pneumonia (16%), and lymphocytic interstitial pneumonia (15%) [2]. We report a case of asymptomatic LIP with extensive HRCT changes before she became symptomatic and developed features of SS, six years later.
2. Case Presentation
A 53-year-old woman was incidentally found to have an abnormal chest radiograph during preoperative assessment for elective hysterectomy, ten years ago. She sought treatment in a hospital in a neighbouring country and was diagnosed with LIP, based on high-resolution computed tomography (HRCT) finding (Figure 1(a)) and lung biopsy report of marked fibrosis of interlobular septa, diffuse interstitial and peribronchiolar lymphoplasmacytic infiltration with scattered eosinophils. She did not receive any treatment and subsequently defaulted follow-up after two years.
Six years after the incidental abnormal chest radiograph, she consulted a respiratory physician with an eight-month history of cough and dyspnoea. Six-minute walk distance was 440 m with oxygen saturation of 89%, and pulmonary function test (PFT) showed a restrictive pattern with FEV1 53%, FVC 67%, and DLCO 70%. A repeat HRCT showed stable appearances of diffuse peribronchovascular thickening and ground glass changes with tiny cysts along the bronchovascular bundles in both lungs (Figure 1(b)). She was referred for a rheumatology consult a few months later when immunology investigations revealed positive antinuclear and anti-Ro antibodies. An additional history of dry eyes, dry mouth, and inflammatory arthralgia, which started three months after the onset of respiratory symptoms, was revealed. She also reported an improvement in her respiratory symptoms a month earlier, after she was prescribed prednisolone 1 mg/kg by a dermatologist for cutaneous vasculitis. At the time of the rheumatology clinic appointment, she was on prednisolone 20 mg and she reported recurrence of cutaneous vasculitis. Physical examination revealed a 52 kg lady with oxygen saturation of 93% on room air at rest, fine crepitations at the lung bases, and multiple vasculitic lesions on the lower limbs. Schirmer's test was positive. Abnormal blood investigations included anaemia (haemoglobin 10.8 g/dL), thrombocytosis (platelet 494 × 109/L), raised erythrocyte sedimentation rate (86 mm/hour), and hypergammaglobulinaemia (globulin 63 g/L). She also had pulmonary hypertension (pH), confirmed by right heart catheterisation showing mean pulmonary arterial pressure of 26 mmHg and precapillary wedge pressure of 9 mmHg.
LIP secondary to primary SS was diagnosed. Prednisolone dose was increased to 0.75 mg/kg and azathioprine 2 mg/kg was started as a steroid-sparing agent. Within the next 18 months, she had three hospitalisations due to worsening respiratory symptoms. She was treated for ILD exacerbation (with high-dose prednisolone) and respiratory tract infection (with intravenous antibiotics). During her last flare, she also developed a recurrence of cutaneous vasculitis. At this time, she agreed for prednisolone but refused steroid-sparing agent. Surprisingly, she remained stable and for the last 10 months; she was well on prednisolone 2.5 mg. She was content with the status quo of NYHA Class II and regular four-monthly clinic follow-up, without any hospitalisations.
3. Discussion
The disease course in our patient highlights some important lessons. First, LIP is a rare disease, and secondary causes should be sought. In some patients, pulmonary involvement precedes other systemic symptoms of CTD, making the distinction between idiopathic ILD and CTD-ILD impossible at the time of diagnosis [3]. Nonetheless, the involvement of multidisciplinary teams is advocated to ensure optimal management of ILD. The diagnosis of SS was delayed in our patient because her rheumatologic symptoms (inflammatory arthralgia, dry eyes, and dry mouth) were not explored when she first presented with cough and dyspnoea. In fact, they were only discovered months later by the rheumatologist, who was referred for positive ANA and anti-Ro antibodies. Without the presence of rheumatologic symptoms and signs, she would be classified as Interstitial Pneumonia with Autoimmune Features (IPAF) [4], as she fulfilled a serologic and morphologic domain only. Some may argue that the classification of IPAF or CTD-ILD is not important as the treatment for both conditions is the same. However, patient monitoring in CTD is different because of multisystem involvement.
Secondly, our patient remained asymptomatic for six years despite extensive HRCT changes. Although CT is the most sensitive method of detecting lung abnormalities, radiological abnormalities do not correlate with pulmonary function tests and respiratory symptoms [5, 6]. The respiratory manifestation of SS is polymorphic and varies in severity [5]. The severity of pulmonary involvement is graded according to PFT results and functional class of patients with HRCT-proven ILD [7]. It is classified as low activity in patients with chronic respiratory symptoms associated with mucosal dryness of the upper respiratory tract with normal imaging and in asymptomatic patients with altered pulmonary imaging [7]. Our patient's disease activity was low in the first six years because she was asymptomatic, but later became moderate because of abnormal PFT and NYHA Class II.
The final lesson is to appreciate that not all pulmonary manifestations in SS need treatment especially those who are well with stable disease [5]. Although there is no conclusive standard therapy for SS with pulmonary involvement, immune therapy such as corticosteroid and/or immunosuppressive drugs is indicated when there is a presence of progressive chest symptoms, impaired respiratory function, or prominent abnormal chest or HRCT [5]. In cases such as our patient, treatment decision with cytotoxic drugs should be weighed carefully between the risk of rendering patients immunocompromised and the risk of patients developing active disease. Patients with LIP generally respond well to initial corticosteroid therapy, but up to one-third may die within several years of diagnosis from the progression of the disease or infectious complications related to immunosuppressive therapy [8]. Based on our experience, we can conclude that LIP in our patient is steroid-responsive, and steroid-sparing agent did not alter her disease course, as she had been stable on a low dose of prednisolone for more than a year.
Conflicts of Interest
The authors declare that there is no conflict of interest regarding the publication of this article.
Figure 1 Selected axial CT images of the initial scan (a) and 6 years later (b) of LIP. There are diffuse peribronchovascular thickening and ground glass changes with tiny cysts along the bronchovascular bundles in both lungs. | AZATHIOPRINE, PREDNISOLONE | DrugsGivenReaction | CC BY | 33505755 | 19,115,360 | 2021 |
Give an alphabetized list of all active substances of drugs taken by the patient who experienced 'Cognitive disorder'. | Successful bilateral electroconvulsive therapy in a patient with a seizure disorder taking levetiracetam, lorazepam, and zonisamide: A case report.
Electroconvulsive therapy (ECT) may be considered for treatment of severe, treatment-resistant, and emergent depression associated with MDD or bipolar disorder. Patients with epilepsy usually take medications that raise the seizure threshold, which poses challenges during ECT. We report a 66-year-old male with epilepsy taking levetiracetam extended-release (XR), lorazepam, and zonisamide requiring ECT for severe MDD. After literature review, the XR form of levetiracetam was changed to higher doses of the immediate-release (IR) formulation, and zonisamide was discontinued 2 days prior to ECT in the hospital and was resumed when the patient underwent outpatient continuation ECT. The patient was treated to remission after receiving 8 acute bilateral ECT treatments before being transitioned to continuation ECT. We provide a brief review of medication management of antiepileptic drugs and other medications that increase the seizure threshold during ECT. To our knowledge, this is the first reported case describing the management of levetiracetam, lorazepam, and zonisamide concomitantly during ECT. Our case suggests that utilizing the IR formulation of levetiracetam, administering the evening dose early the day prior to the procedure, and temporarily discontinuing zonisamide prior to bilateral ECT is effective for the treatment of severe MDD while maintaining seizure prophylaxis.
Background
Most treatment guidelines support the use of electroconvulsive therapy (ECT) in severe, treatment-resistant, or emergent cases of MDD.1,2 The neuronal mechanism of ECT seen in MDD is unclear with the main theory being that seizures induce changes in neurotransmitters, neuroplasticity, and brain tissue connectivity.1,3 Patients with epilepsy requiring ECT likely receive seizure threshold–raising medications, such as benzodiazepines (BZDs) or antiepileptic drugs (AEDs). The goal of medication management in such cases is to achieve adequate seizure (eg, 30 to 90 seconds) during ECT without causing spontaneous seizures.4,5 ECT is often delivered using brief pulse width and electrical intensity and titrated based on minimum intensity to exceed the seizure threshold.1 Because BZDs and AEDs may diminish ECT response, considerations can be made to alter the anesthetic regimen prior to ECT, use flumazenil prior to ECT in patients using BZDs, and decrease or withhold the evening and/or morning doses of seizure threshold–increasing medications prior to ECT.5 Contradictory to this, studies have shown unilateral, bifrontal, or bitemporal ECT to be effective in patients with primarily nonepileptic mood disorders taking AEDs,6-8 and BZDs may not negatively affect ECT outcomes in patients with depression.3 In patients with seizure disorders undergoing ECT, it has been suggested to continue AEDs with neurology consultation and, in the event of medication alterations, return AEDs to previously prescribed doses after ECT is concluded.4 To our knowledge, we report the first patient with MDD and a seizure disorder managed with bilateral ECT who was taking levetiracetam, lorazepam, and zonisamide.
Case Report
Our patient is a 66-year-old male with MDD with psychotic features, unspecified anxiety disorder, and generalized tonic-clonic seizures admitted to the psychiatric hospital with suicidal thoughts. He presented with profound psychomotor retardation, cognitive latency, thought blocking, anorexia with weight loss, and difficulty with sleep maintenance. The patient also had nihilistic-type delusions that he was already dead or imminently dying. The patient had been seizure-free with no AED changes for at least 1 year. Medications at admission included fluoxetine 20 mg daily, levetiracetam 750 mg extended-release (XR) nightly, lorazepam 1 mg every morning and 2 mg every evening, and zonisamide 300 mg nightly. He initiated fluoxetine and lorazepam within the preceding month. Previous trials of escitalopram and quetiapine were not effective; mirtazapine was briefly effective. Fluoxetine and lorazepam were discontinued on the day of admission due to ineffectiveness and the possibility of worsening cognitive dysfunction, respectively. Oral venlafaxine 75 mg daily and mirtazapine 15 mg nightly were initiated on admission with considerations to start ECT if ineffective. Two days later, he began to refuse all medications and required assistance eating. On the third evening, he had an approximate 60-second seizure, which required transfer to the emergency department and treatment with IV levetiracetam and lorazepam and oral zonisamide. Lorazepam was continued IV at 0.5 mg 4 times daily on day 4, which improved his ability to take medications and make decisions. It was determined that ECT would be appropriate, but the patient was not ready to consent. Nonetheless, pharmacotherapy was modified in order to prepare for ECT. After literature review and discussion with neurology, levetiracetam was switched to 1000 mg immediate-release (IR) twice daily with the evening dose to be given at 2 pm the night prior to ECT while holding the morning dose on the day of ECT. Lorazepam was reduced to 0.25 mg 4 times daily on the seventh day of hospitalization and discontinued on the ninth day. Zonisamide was tapered and discontinued 2 days prior to the first ECT session and withheld during the remainder of hospitalization. The patient was observed to have a limited-duration seizure 2 days prior to initial ECT that may have been related to downward taper of AEDs. After deliberation, the patient agreed to ECT, and the acute series was initiated on day 12 for a total of 8 sessions (Table). ECT was administered with the Thymatron System IV (Somatics, LLC, Venice, FL) with a pulse width of 0.5 ms, 30 Hz, 40 joules, and duration of 7.5 seconds. Methohexital was the anesthesia-inducing agent used. Adequate seizure activity was seen (Table). He restarted oral lorazepam 0.5 mg twice daily after the first ECT for continued neurovegatative symptoms while holding the nightly dose prior to ECT. After the second ECT, improvements were robust across all domains of prior dysfunction; the patient was engaging socially, smiling, eating, and sleeping; mood was much improved, and delusions resolved. Following the fourth ECT, lorazepam was no longer indicated and discontinued. The patient discharged home after the fifth ECT, completed 8 acute treatments, and received continuation ECT following this. Following the acute ECT series, the patient resumed zonisamide and levetiracetam XR at previously prescribed doses. The patient held these AEDs 4 days prior to each continuation ECT and utilized twice daily levetiracetam 1000 mg IR monotherapy with the last dose at least 24 hours before ECT. Nights following continuation ECT, zonisamide and levetiracetam XR were resumed. After the 10th treatment, the patient sustained resolution of depressive symptoms, denying insomnia, anhedonia, and suicidal thoughts.
TABLE Electrode placement and seizure duration during electroconvulsive therapy (ECT) course
Treatment No. 1 2 3 4 5 6 7 8 9 10 11 12
Days since ECT initiation 0 2 5 7 9 12 14 16 30 44 65 100
Electrode placement BT BT BT BF BT BT BT BT RUL BT BT BT
Seizure duration, s
Motor 28 39 28 32 27 25 24 24 16 30 21 38
EEG 51 63 51 48 53 51 42 38 39 64 48 68
BF = bifrontal; BT = bitemporal; EEG = electroencephalogram; RUL = right unilateral.
Discussion
It is not clearly understood how AEDs affect ECT response, and there is no consensus on AED management. Although several studies report successful ECT with AEDs,6-8 no reports are available for the management of levetiracetam combined with zonisamide during ECT. We implemented a careful administration schedule for our patient's AEDs based on their pharmacokinetic properties, balancing the goals of seizure prevention with ECT response. It was of high importance to obtain rapid depression improvement, and given our patient's seizure-free duration prior to admission, antiepileptic medications were reduced with input from neurology. Our patient had adequate seizures during ECT with no restimulations required and no breakthrough seizures once ECT was initiated.
Zonisamide was discontinued 2 days prior to ECT initiation and resumed after acute ECT series completion. Zonisamide achieves peak concentrations 2 to 6 hours after administration and reaches concentration steady-state in approximately 2 weeks.9 In an effort to reduce seizure occurrence when not being administered ECT and also allow for quicker AED elimination on nights prior to ECT, levetiracetam was switched from the XR formulation to a higher dose of the IR formulation. Levetiracetam XR peak plasma concentrations occurs after 4 hours with peak time being 3 hours longer than the IR formulation. The elimination half-life of levetiracetam is 9 hours in the elderly with comparable bioavailability between the XR and IR formulations.10 Given its elimination half-life, zonisamide would likely have had detectable serum concentrations during this patient's course of treatment, yet it did not prevent adequate seizure duration during ECT. Similarly, we did not see adverse impacts on treatment response or occurrence of breakthrough seizure from the increased levetiracetam IR dose prescribed.
There is debate regarding the optimal anesthetic agent to be used during ECT.11 Although etomidate monotherapy or adding ramifentanyl to lower doses of methohexital for anesthesia induction if inadequate seizures occur during ECT can be considered,5 we continued our current practice of using the barbituric acid derivative, methohexital, as an inducing agent and altered the AEDs as described previously. One randomized, double-blind, crossover trial12 compared etomidate, methohexital, and propofol as inducing agents for ECT in 10 patients with MDD; however, none of these patients had seizure disorders or took AEDs. Briefly, EEG seizures were longest after etomidate induction and shortest with propofol, and the clinical meaningfulness of this effect was not assessed.12 Etomidate had no dose-related differences in EEG seizure duration although higher weight-based doses of methohexital and propofol reduced seizure duration. Cognitive recovery was longer in patients with longer seizure duration, and discharge time from recovery room was 5 to 7 minutes longer with etomidate compared with other agents.12 A meta-analysis, including open-label trials and case series, found etomidate EEG seizure duration to be 2.23 seconds (95% CI = –3.62, 8.01; P = .456) longer than methohexital.12 Based on this data, etomidate as an inducing agent does not clearly offer an advantage in patients with epilepsy taking AEDs but could be considered.
Our use of low-dose lorazepam with brief washout periods the night prior to ECT procedures also appeared to have little impact on bitemporal ECT effectiveness. Data suggest BZDs decrease the efficacy of unilateral ECT13,14 but perhaps not during bilateral ECT. Retrospective data suggest patients receiving BZDs had higher depression remission rates than those not receiving BZDs (81.8% vs 52%, P = .017) during primarily bilateral ECT.3 Another retrospective study found patients with monopolar depression who received an average of 17.95 mg (SD 20.3) diazepam equivalents had a response rate of 98.9% and a remission rate of 90% with bitemporal ECT.15
Our case demonstrates that bilateral ECT effectiveness was not compromised with the use of low-dose lorazepam, levetiracetam, and lack of complete zonisamide elimination prior to the procedure. Limitations to our case include that it represents a single patient, AED and BZD serum concentrations were not monitored, and no standardized depression rating scales were utilized. Although our management of this case appears promising for successfully continuing lorazepam, levetiracetam, and zonisamide during ECT, more research and case reports are necessary to recommend safe and effective utilization of AEDs and BZDs during ECT.
Conclusion
Management of AEDs and BZDs during ECT poses challenges, especially in patients with seizure disorders. Valproate, carbamazepine, and lamotrigine have been successfully continued during ECT in patients without epilepsy,6-8 and a large case series supports AED continuation in most patients with epilepsy receiving ECT.4 BZDs do not usually impact ECT effectiveness when the dose is held the morning prior to bilateral ECT procedures.3,15 Our case suggests that utilizing the IR formulation of levetiracetam, administering the evening dose early the day prior to the procedure, and temporarily discontinuing zonisamide dosing prior to bilateral ECT is effective for the treatment of severe MDD while maintaining seizure prophylaxis. | FLUOXETINE HYDROCHLORIDE, LEVETIRACETAM, LORAZEPAM, ZONISAMIDE | DrugsGivenReaction | CC BY-NC | 33505822 | 18,944,740 | 2021-01 |
Give an alphabetized list of all active substances of drugs taken by the patient who experienced 'Condition aggravated'. | Successful bilateral electroconvulsive therapy in a patient with a seizure disorder taking levetiracetam, lorazepam, and zonisamide: A case report.
Electroconvulsive therapy (ECT) may be considered for treatment of severe, treatment-resistant, and emergent depression associated with MDD or bipolar disorder. Patients with epilepsy usually take medications that raise the seizure threshold, which poses challenges during ECT. We report a 66-year-old male with epilepsy taking levetiracetam extended-release (XR), lorazepam, and zonisamide requiring ECT for severe MDD. After literature review, the XR form of levetiracetam was changed to higher doses of the immediate-release (IR) formulation, and zonisamide was discontinued 2 days prior to ECT in the hospital and was resumed when the patient underwent outpatient continuation ECT. The patient was treated to remission after receiving 8 acute bilateral ECT treatments before being transitioned to continuation ECT. We provide a brief review of medication management of antiepileptic drugs and other medications that increase the seizure threshold during ECT. To our knowledge, this is the first reported case describing the management of levetiracetam, lorazepam, and zonisamide concomitantly during ECT. Our case suggests that utilizing the IR formulation of levetiracetam, administering the evening dose early the day prior to the procedure, and temporarily discontinuing zonisamide prior to bilateral ECT is effective for the treatment of severe MDD while maintaining seizure prophylaxis.
Background
Most treatment guidelines support the use of electroconvulsive therapy (ECT) in severe, treatment-resistant, or emergent cases of MDD.1,2 The neuronal mechanism of ECT seen in MDD is unclear with the main theory being that seizures induce changes in neurotransmitters, neuroplasticity, and brain tissue connectivity.1,3 Patients with epilepsy requiring ECT likely receive seizure threshold–raising medications, such as benzodiazepines (BZDs) or antiepileptic drugs (AEDs). The goal of medication management in such cases is to achieve adequate seizure (eg, 30 to 90 seconds) during ECT without causing spontaneous seizures.4,5 ECT is often delivered using brief pulse width and electrical intensity and titrated based on minimum intensity to exceed the seizure threshold.1 Because BZDs and AEDs may diminish ECT response, considerations can be made to alter the anesthetic regimen prior to ECT, use flumazenil prior to ECT in patients using BZDs, and decrease or withhold the evening and/or morning doses of seizure threshold–increasing medications prior to ECT.5 Contradictory to this, studies have shown unilateral, bifrontal, or bitemporal ECT to be effective in patients with primarily nonepileptic mood disorders taking AEDs,6-8 and BZDs may not negatively affect ECT outcomes in patients with depression.3 In patients with seizure disorders undergoing ECT, it has been suggested to continue AEDs with neurology consultation and, in the event of medication alterations, return AEDs to previously prescribed doses after ECT is concluded.4 To our knowledge, we report the first patient with MDD and a seizure disorder managed with bilateral ECT who was taking levetiracetam, lorazepam, and zonisamide.
Case Report
Our patient is a 66-year-old male with MDD with psychotic features, unspecified anxiety disorder, and generalized tonic-clonic seizures admitted to the psychiatric hospital with suicidal thoughts. He presented with profound psychomotor retardation, cognitive latency, thought blocking, anorexia with weight loss, and difficulty with sleep maintenance. The patient also had nihilistic-type delusions that he was already dead or imminently dying. The patient had been seizure-free with no AED changes for at least 1 year. Medications at admission included fluoxetine 20 mg daily, levetiracetam 750 mg extended-release (XR) nightly, lorazepam 1 mg every morning and 2 mg every evening, and zonisamide 300 mg nightly. He initiated fluoxetine and lorazepam within the preceding month. Previous trials of escitalopram and quetiapine were not effective; mirtazapine was briefly effective. Fluoxetine and lorazepam were discontinued on the day of admission due to ineffectiveness and the possibility of worsening cognitive dysfunction, respectively. Oral venlafaxine 75 mg daily and mirtazapine 15 mg nightly were initiated on admission with considerations to start ECT if ineffective. Two days later, he began to refuse all medications and required assistance eating. On the third evening, he had an approximate 60-second seizure, which required transfer to the emergency department and treatment with IV levetiracetam and lorazepam and oral zonisamide. Lorazepam was continued IV at 0.5 mg 4 times daily on day 4, which improved his ability to take medications and make decisions. It was determined that ECT would be appropriate, but the patient was not ready to consent. Nonetheless, pharmacotherapy was modified in order to prepare for ECT. After literature review and discussion with neurology, levetiracetam was switched to 1000 mg immediate-release (IR) twice daily with the evening dose to be given at 2 pm the night prior to ECT while holding the morning dose on the day of ECT. Lorazepam was reduced to 0.25 mg 4 times daily on the seventh day of hospitalization and discontinued on the ninth day. Zonisamide was tapered and discontinued 2 days prior to the first ECT session and withheld during the remainder of hospitalization. The patient was observed to have a limited-duration seizure 2 days prior to initial ECT that may have been related to downward taper of AEDs. After deliberation, the patient agreed to ECT, and the acute series was initiated on day 12 for a total of 8 sessions (Table). ECT was administered with the Thymatron System IV (Somatics, LLC, Venice, FL) with a pulse width of 0.5 ms, 30 Hz, 40 joules, and duration of 7.5 seconds. Methohexital was the anesthesia-inducing agent used. Adequate seizure activity was seen (Table). He restarted oral lorazepam 0.5 mg twice daily after the first ECT for continued neurovegatative symptoms while holding the nightly dose prior to ECT. After the second ECT, improvements were robust across all domains of prior dysfunction; the patient was engaging socially, smiling, eating, and sleeping; mood was much improved, and delusions resolved. Following the fourth ECT, lorazepam was no longer indicated and discontinued. The patient discharged home after the fifth ECT, completed 8 acute treatments, and received continuation ECT following this. Following the acute ECT series, the patient resumed zonisamide and levetiracetam XR at previously prescribed doses. The patient held these AEDs 4 days prior to each continuation ECT and utilized twice daily levetiracetam 1000 mg IR monotherapy with the last dose at least 24 hours before ECT. Nights following continuation ECT, zonisamide and levetiracetam XR were resumed. After the 10th treatment, the patient sustained resolution of depressive symptoms, denying insomnia, anhedonia, and suicidal thoughts.
TABLE Electrode placement and seizure duration during electroconvulsive therapy (ECT) course
Treatment No. 1 2 3 4 5 6 7 8 9 10 11 12
Days since ECT initiation 0 2 5 7 9 12 14 16 30 44 65 100
Electrode placement BT BT BT BF BT BT BT BT RUL BT BT BT
Seizure duration, s
Motor 28 39 28 32 27 25 24 24 16 30 21 38
EEG 51 63 51 48 53 51 42 38 39 64 48 68
BF = bifrontal; BT = bitemporal; EEG = electroencephalogram; RUL = right unilateral.
Discussion
It is not clearly understood how AEDs affect ECT response, and there is no consensus on AED management. Although several studies report successful ECT with AEDs,6-8 no reports are available for the management of levetiracetam combined with zonisamide during ECT. We implemented a careful administration schedule for our patient's AEDs based on their pharmacokinetic properties, balancing the goals of seizure prevention with ECT response. It was of high importance to obtain rapid depression improvement, and given our patient's seizure-free duration prior to admission, antiepileptic medications were reduced with input from neurology. Our patient had adequate seizures during ECT with no restimulations required and no breakthrough seizures once ECT was initiated.
Zonisamide was discontinued 2 days prior to ECT initiation and resumed after acute ECT series completion. Zonisamide achieves peak concentrations 2 to 6 hours after administration and reaches concentration steady-state in approximately 2 weeks.9 In an effort to reduce seizure occurrence when not being administered ECT and also allow for quicker AED elimination on nights prior to ECT, levetiracetam was switched from the XR formulation to a higher dose of the IR formulation. Levetiracetam XR peak plasma concentrations occurs after 4 hours with peak time being 3 hours longer than the IR formulation. The elimination half-life of levetiracetam is 9 hours in the elderly with comparable bioavailability between the XR and IR formulations.10 Given its elimination half-life, zonisamide would likely have had detectable serum concentrations during this patient's course of treatment, yet it did not prevent adequate seizure duration during ECT. Similarly, we did not see adverse impacts on treatment response or occurrence of breakthrough seizure from the increased levetiracetam IR dose prescribed.
There is debate regarding the optimal anesthetic agent to be used during ECT.11 Although etomidate monotherapy or adding ramifentanyl to lower doses of methohexital for anesthesia induction if inadequate seizures occur during ECT can be considered,5 we continued our current practice of using the barbituric acid derivative, methohexital, as an inducing agent and altered the AEDs as described previously. One randomized, double-blind, crossover trial12 compared etomidate, methohexital, and propofol as inducing agents for ECT in 10 patients with MDD; however, none of these patients had seizure disorders or took AEDs. Briefly, EEG seizures were longest after etomidate induction and shortest with propofol, and the clinical meaningfulness of this effect was not assessed.12 Etomidate had no dose-related differences in EEG seizure duration although higher weight-based doses of methohexital and propofol reduced seizure duration. Cognitive recovery was longer in patients with longer seizure duration, and discharge time from recovery room was 5 to 7 minutes longer with etomidate compared with other agents.12 A meta-analysis, including open-label trials and case series, found etomidate EEG seizure duration to be 2.23 seconds (95% CI = –3.62, 8.01; P = .456) longer than methohexital.12 Based on this data, etomidate as an inducing agent does not clearly offer an advantage in patients with epilepsy taking AEDs but could be considered.
Our use of low-dose lorazepam with brief washout periods the night prior to ECT procedures also appeared to have little impact on bitemporal ECT effectiveness. Data suggest BZDs decrease the efficacy of unilateral ECT13,14 but perhaps not during bilateral ECT. Retrospective data suggest patients receiving BZDs had higher depression remission rates than those not receiving BZDs (81.8% vs 52%, P = .017) during primarily bilateral ECT.3 Another retrospective study found patients with monopolar depression who received an average of 17.95 mg (SD 20.3) diazepam equivalents had a response rate of 98.9% and a remission rate of 90% with bitemporal ECT.15
Our case demonstrates that bilateral ECT effectiveness was not compromised with the use of low-dose lorazepam, levetiracetam, and lack of complete zonisamide elimination prior to the procedure. Limitations to our case include that it represents a single patient, AED and BZD serum concentrations were not monitored, and no standardized depression rating scales were utilized. Although our management of this case appears promising for successfully continuing lorazepam, levetiracetam, and zonisamide during ECT, more research and case reports are necessary to recommend safe and effective utilization of AEDs and BZDs during ECT.
Conclusion
Management of AEDs and BZDs during ECT poses challenges, especially in patients with seizure disorders. Valproate, carbamazepine, and lamotrigine have been successfully continued during ECT in patients without epilepsy,6-8 and a large case series supports AED continuation in most patients with epilepsy receiving ECT.4 BZDs do not usually impact ECT effectiveness when the dose is held the morning prior to bilateral ECT procedures.3,15 Our case suggests that utilizing the IR formulation of levetiracetam, administering the evening dose early the day prior to the procedure, and temporarily discontinuing zonisamide dosing prior to bilateral ECT is effective for the treatment of severe MDD while maintaining seizure prophylaxis. | FLUOXETINE HYDROCHLORIDE, LEVETIRACETAM, LORAZEPAM, ZONISAMIDE | DrugsGivenReaction | CC BY-NC | 33505822 | 18,944,740 | 2021-01 |
What was the administration route of drug 'LEVETIRACETAM'? | Successful bilateral electroconvulsive therapy in a patient with a seizure disorder taking levetiracetam, lorazepam, and zonisamide: A case report.
Electroconvulsive therapy (ECT) may be considered for treatment of severe, treatment-resistant, and emergent depression associated with MDD or bipolar disorder. Patients with epilepsy usually take medications that raise the seizure threshold, which poses challenges during ECT. We report a 66-year-old male with epilepsy taking levetiracetam extended-release (XR), lorazepam, and zonisamide requiring ECT for severe MDD. After literature review, the XR form of levetiracetam was changed to higher doses of the immediate-release (IR) formulation, and zonisamide was discontinued 2 days prior to ECT in the hospital and was resumed when the patient underwent outpatient continuation ECT. The patient was treated to remission after receiving 8 acute bilateral ECT treatments before being transitioned to continuation ECT. We provide a brief review of medication management of antiepileptic drugs and other medications that increase the seizure threshold during ECT. To our knowledge, this is the first reported case describing the management of levetiracetam, lorazepam, and zonisamide concomitantly during ECT. Our case suggests that utilizing the IR formulation of levetiracetam, administering the evening dose early the day prior to the procedure, and temporarily discontinuing zonisamide prior to bilateral ECT is effective for the treatment of severe MDD while maintaining seizure prophylaxis.
Background
Most treatment guidelines support the use of electroconvulsive therapy (ECT) in severe, treatment-resistant, or emergent cases of MDD.1,2 The neuronal mechanism of ECT seen in MDD is unclear with the main theory being that seizures induce changes in neurotransmitters, neuroplasticity, and brain tissue connectivity.1,3 Patients with epilepsy requiring ECT likely receive seizure threshold–raising medications, such as benzodiazepines (BZDs) or antiepileptic drugs (AEDs). The goal of medication management in such cases is to achieve adequate seizure (eg, 30 to 90 seconds) during ECT without causing spontaneous seizures.4,5 ECT is often delivered using brief pulse width and electrical intensity and titrated based on minimum intensity to exceed the seizure threshold.1 Because BZDs and AEDs may diminish ECT response, considerations can be made to alter the anesthetic regimen prior to ECT, use flumazenil prior to ECT in patients using BZDs, and decrease or withhold the evening and/or morning doses of seizure threshold–increasing medications prior to ECT.5 Contradictory to this, studies have shown unilateral, bifrontal, or bitemporal ECT to be effective in patients with primarily nonepileptic mood disorders taking AEDs,6-8 and BZDs may not negatively affect ECT outcomes in patients with depression.3 In patients with seizure disorders undergoing ECT, it has been suggested to continue AEDs with neurology consultation and, in the event of medication alterations, return AEDs to previously prescribed doses after ECT is concluded.4 To our knowledge, we report the first patient with MDD and a seizure disorder managed with bilateral ECT who was taking levetiracetam, lorazepam, and zonisamide.
Case Report
Our patient is a 66-year-old male with MDD with psychotic features, unspecified anxiety disorder, and generalized tonic-clonic seizures admitted to the psychiatric hospital with suicidal thoughts. He presented with profound psychomotor retardation, cognitive latency, thought blocking, anorexia with weight loss, and difficulty with sleep maintenance. The patient also had nihilistic-type delusions that he was already dead or imminently dying. The patient had been seizure-free with no AED changes for at least 1 year. Medications at admission included fluoxetine 20 mg daily, levetiracetam 750 mg extended-release (XR) nightly, lorazepam 1 mg every morning and 2 mg every evening, and zonisamide 300 mg nightly. He initiated fluoxetine and lorazepam within the preceding month. Previous trials of escitalopram and quetiapine were not effective; mirtazapine was briefly effective. Fluoxetine and lorazepam were discontinued on the day of admission due to ineffectiveness and the possibility of worsening cognitive dysfunction, respectively. Oral venlafaxine 75 mg daily and mirtazapine 15 mg nightly were initiated on admission with considerations to start ECT if ineffective. Two days later, he began to refuse all medications and required assistance eating. On the third evening, he had an approximate 60-second seizure, which required transfer to the emergency department and treatment with IV levetiracetam and lorazepam and oral zonisamide. Lorazepam was continued IV at 0.5 mg 4 times daily on day 4, which improved his ability to take medications and make decisions. It was determined that ECT would be appropriate, but the patient was not ready to consent. Nonetheless, pharmacotherapy was modified in order to prepare for ECT. After literature review and discussion with neurology, levetiracetam was switched to 1000 mg immediate-release (IR) twice daily with the evening dose to be given at 2 pm the night prior to ECT while holding the morning dose on the day of ECT. Lorazepam was reduced to 0.25 mg 4 times daily on the seventh day of hospitalization and discontinued on the ninth day. Zonisamide was tapered and discontinued 2 days prior to the first ECT session and withheld during the remainder of hospitalization. The patient was observed to have a limited-duration seizure 2 days prior to initial ECT that may have been related to downward taper of AEDs. After deliberation, the patient agreed to ECT, and the acute series was initiated on day 12 for a total of 8 sessions (Table). ECT was administered with the Thymatron System IV (Somatics, LLC, Venice, FL) with a pulse width of 0.5 ms, 30 Hz, 40 joules, and duration of 7.5 seconds. Methohexital was the anesthesia-inducing agent used. Adequate seizure activity was seen (Table). He restarted oral lorazepam 0.5 mg twice daily after the first ECT for continued neurovegatative symptoms while holding the nightly dose prior to ECT. After the second ECT, improvements were robust across all domains of prior dysfunction; the patient was engaging socially, smiling, eating, and sleeping; mood was much improved, and delusions resolved. Following the fourth ECT, lorazepam was no longer indicated and discontinued. The patient discharged home after the fifth ECT, completed 8 acute treatments, and received continuation ECT following this. Following the acute ECT series, the patient resumed zonisamide and levetiracetam XR at previously prescribed doses. The patient held these AEDs 4 days prior to each continuation ECT and utilized twice daily levetiracetam 1000 mg IR monotherapy with the last dose at least 24 hours before ECT. Nights following continuation ECT, zonisamide and levetiracetam XR were resumed. After the 10th treatment, the patient sustained resolution of depressive symptoms, denying insomnia, anhedonia, and suicidal thoughts.
TABLE Electrode placement and seizure duration during electroconvulsive therapy (ECT) course
Treatment No. 1 2 3 4 5 6 7 8 9 10 11 12
Days since ECT initiation 0 2 5 7 9 12 14 16 30 44 65 100
Electrode placement BT BT BT BF BT BT BT BT RUL BT BT BT
Seizure duration, s
Motor 28 39 28 32 27 25 24 24 16 30 21 38
EEG 51 63 51 48 53 51 42 38 39 64 48 68
BF = bifrontal; BT = bitemporal; EEG = electroencephalogram; RUL = right unilateral.
Discussion
It is not clearly understood how AEDs affect ECT response, and there is no consensus on AED management. Although several studies report successful ECT with AEDs,6-8 no reports are available for the management of levetiracetam combined with zonisamide during ECT. We implemented a careful administration schedule for our patient's AEDs based on their pharmacokinetic properties, balancing the goals of seizure prevention with ECT response. It was of high importance to obtain rapid depression improvement, and given our patient's seizure-free duration prior to admission, antiepileptic medications were reduced with input from neurology. Our patient had adequate seizures during ECT with no restimulations required and no breakthrough seizures once ECT was initiated.
Zonisamide was discontinued 2 days prior to ECT initiation and resumed after acute ECT series completion. Zonisamide achieves peak concentrations 2 to 6 hours after administration and reaches concentration steady-state in approximately 2 weeks.9 In an effort to reduce seizure occurrence when not being administered ECT and also allow for quicker AED elimination on nights prior to ECT, levetiracetam was switched from the XR formulation to a higher dose of the IR formulation. Levetiracetam XR peak plasma concentrations occurs after 4 hours with peak time being 3 hours longer than the IR formulation. The elimination half-life of levetiracetam is 9 hours in the elderly with comparable bioavailability between the XR and IR formulations.10 Given its elimination half-life, zonisamide would likely have had detectable serum concentrations during this patient's course of treatment, yet it did not prevent adequate seizure duration during ECT. Similarly, we did not see adverse impacts on treatment response or occurrence of breakthrough seizure from the increased levetiracetam IR dose prescribed.
There is debate regarding the optimal anesthetic agent to be used during ECT.11 Although etomidate monotherapy or adding ramifentanyl to lower doses of methohexital for anesthesia induction if inadequate seizures occur during ECT can be considered,5 we continued our current practice of using the barbituric acid derivative, methohexital, as an inducing agent and altered the AEDs as described previously. One randomized, double-blind, crossover trial12 compared etomidate, methohexital, and propofol as inducing agents for ECT in 10 patients with MDD; however, none of these patients had seizure disorders or took AEDs. Briefly, EEG seizures were longest after etomidate induction and shortest with propofol, and the clinical meaningfulness of this effect was not assessed.12 Etomidate had no dose-related differences in EEG seizure duration although higher weight-based doses of methohexital and propofol reduced seizure duration. Cognitive recovery was longer in patients with longer seizure duration, and discharge time from recovery room was 5 to 7 minutes longer with etomidate compared with other agents.12 A meta-analysis, including open-label trials and case series, found etomidate EEG seizure duration to be 2.23 seconds (95% CI = –3.62, 8.01; P = .456) longer than methohexital.12 Based on this data, etomidate as an inducing agent does not clearly offer an advantage in patients with epilepsy taking AEDs but could be considered.
Our use of low-dose lorazepam with brief washout periods the night prior to ECT procedures also appeared to have little impact on bitemporal ECT effectiveness. Data suggest BZDs decrease the efficacy of unilateral ECT13,14 but perhaps not during bilateral ECT. Retrospective data suggest patients receiving BZDs had higher depression remission rates than those not receiving BZDs (81.8% vs 52%, P = .017) during primarily bilateral ECT.3 Another retrospective study found patients with monopolar depression who received an average of 17.95 mg (SD 20.3) diazepam equivalents had a response rate of 98.9% and a remission rate of 90% with bitemporal ECT.15
Our case demonstrates that bilateral ECT effectiveness was not compromised with the use of low-dose lorazepam, levetiracetam, and lack of complete zonisamide elimination prior to the procedure. Limitations to our case include that it represents a single patient, AED and BZD serum concentrations were not monitored, and no standardized depression rating scales were utilized. Although our management of this case appears promising for successfully continuing lorazepam, levetiracetam, and zonisamide during ECT, more research and case reports are necessary to recommend safe and effective utilization of AEDs and BZDs during ECT.
Conclusion
Management of AEDs and BZDs during ECT poses challenges, especially in patients with seizure disorders. Valproate, carbamazepine, and lamotrigine have been successfully continued during ECT in patients without epilepsy,6-8 and a large case series supports AED continuation in most patients with epilepsy receiving ECT.4 BZDs do not usually impact ECT effectiveness when the dose is held the morning prior to bilateral ECT procedures.3,15 Our case suggests that utilizing the IR formulation of levetiracetam, administering the evening dose early the day prior to the procedure, and temporarily discontinuing zonisamide dosing prior to bilateral ECT is effective for the treatment of severe MDD while maintaining seizure prophylaxis. | Oral | DrugAdministrationRoute | CC BY-NC | 33505822 | 18,944,740 | 2021-01 |
Give an alphabetized list of all active substances of drugs taken by the patient who experienced 'Drug ineffective'. | Continuous Glucose Monitoring to Diagnose Hypoglycemia Due to Late Dumping Syndrome in Children After Gastric Surgeries.
Gastrostomy tubes (G-tubes) and Nissen fundoplication are common surgical interventions for feeding difficulties and gastroesophageal reflux disease in children. A potential yet often missed, complication of these procedures is dumping syndrome. We present 3 pediatric patients with postprandial hypoglycemia due to late dumping syndrome after gastric surgeries. All patients received gastrostomy tubes for feeding intolerance: 2 had Nissen fundoplication for gastroesophageal reflux disease, and 1 had tracheoesophageal repair. All patients underwent multiple imaging studies in an to attempt to diagnose dumping syndrome. Continuous glucose monitoring (CGM) was essential for detecting asymptomatic hypoglycemia and glycemic excursions occurring with feeds that would have gone undetected with point-of-care (POC) blood glucose checks. CGM was also used to monitor the effectiveness of treatment strategies and drive treatment plans. These cases highlight the utility of CGM in diagnosing postprandial hypoglycemia due to late dumping syndrome, which is infrequently diagnosed by imaging studies and intermittent POC blood glucose measurements.
Gastrostomy tubes (G-tubes) and Nissen fundoplications are increasingly employed to treat feeding intolerance and gastroesophageal reflux disease (GERD) in children. Removing the barrier function of the pylorus or reducing gastric volume can lead to undigested food rapidly entering the small intestine, which can result in dumping syndrome [1]. The symptoms of dumping syndrome are classified as early and late, which can occur together or in isolation. Early dumping syndrome typically occurs within the first hour after eating with gastrointestinal and vasomotor symptoms including nausea, vomiting, abdominal cramping, sweating, tachycardia, and dizziness. Late dumping syndrome, also referred to as reactive or postprandial hyperinsulinemic hypoglycemia, typically occurs 1 to 3 hours after eating and manifests as hypoglycemia due to a hyperinsulinemic response. Exaggerated secretion of glucagon-like peptide 1 (GLP-1) has been implicated as a key mediator of postprandial hypoglycemia in late dumping syndrome [2].
The diagnosis of late dumping syndrome can be particularly elusive in children. The signs and symptoms may go unrecognized, especially in younger children. In addition, recurrent episodes of hypoglycemia may result in hypoglycemia unawareness [3], compounding the challenges in making the diagnosis. Further complicating the diagnosis is the lack of consensus guidelines for diagnosing dumping syndrome in the pediatric population.
Herein, we present a case series of 3 children with postprandial hypoglycemia due to late dumping syndrome. Although imaging studies did not indicate dumping syndrome, continuous glucose monitoring (CGM) proved to be a useful adjunctive study for both the diagnosis and assessment of the effectiveness of therapy.
Case Series
The patients presented to our institution between 2015 and 2019. Table 1 summarizes the clinical characteristics of the patients. Two of the patients received a Nissen fundoplication for GERD and one patient underwent gastroesophageal repair for tracheoesophageal fistula. All patients had feeding intolerance manifested by frequent vomiting and aspiration, for which a G-tube was placed. CGM (Dexcom; San Diego, California) devices were placed on the patients to better evaluate the glycemic patterns associated with feeds. Dexcom G4, G5, and G6 devices were used and calibrated per industry recommendations. The data stored by the CGM devices were uploaded to Dexcom Clarity or Tidepool, a web-based cloud software system for collecting and visualizing diabetes device data [4].
Table 1. Patient Characteristics
Patient Age at presentation (months) Past medical history Surgery (age at surgery) Feeding regimen at presentation Diagnostic test Imaging studies (result) Glucose monitoring Treatment
1 8-9 FTT, GERD G-tube and Nissen fundoplication (6 months) Oral and enteral MMTT Nuclear medicine study × 2 (normal) Inpatient: CGM Outpatient: Glucometer Acarbose prior to meals
2 9 Chronic aspiration, hypotonia, GERD G-tube and Nissen fundoplication (7 months) Enteral OGTT Gastric emptying study × 2 (severely delayed gastric emptying) Inpatient: CGM Feeding manipulation
Outpatient: CGM Acarbose prior to bolus feeds unsuccessful
Upper GI study (normal) Cornstarch with bolus feeds unsuccessful
3 13 Esophageal atresia and distal tracheoesophageal fistula (EA-TEF type C) G-tube and tracheoesophageal repair and dilations (0 months) Enteral MMTT Gastric emptying study (normal) Inpatient: CGM Feeding manipulation
Outpatient: Glucometer Cornstarch with bolus feeds
Abbreviations: CGM, continuous glucose monitoring; FTT, failure to thrive; MMT, mixed-meal tolerance test; OGTT, oral glucose tolerance test.
Patient 1
A 9-month-old full-term male infant with a history of poor growth and severe GERD status post-Nissen fundoplication and G-tube placement presented with labile blood glucoses (BG) ranging from 50 to 200 mg/dL. Loose stools occurred after G-tube feeds and, in retrospect, the child seemed fatigued after feeds. He had a previous hospitalization at age 8 months for hypoglycemia; however, no critical sample was captured, and a nuclear medicine gastric emptying study was normal.
He was again hospitalized for extensive workup of glucose lability at 9 months of age. Physical exam was unremarkable with an alert and interactive infant with normal phallus and no midline defects. It was difficult to capture the timing of the hypoglycemia with POC blood glucose monitoring, so a CGM device was placed. He underwent a 16-hour fast and then demonstrated physiologic, ketotic hypoglycemia and a blunted glucose response to glucagon, with a lack of counter-regulatory cortisol rise (Table 2). Subsequent anterior pituitary workup, including a cosyntropin stimulation test, was normal. Given the postprandial hyperglycemia and hypoglycemia, there was suspicion for glycogen storage disease type 0 (GSD0). Liver ultrasound was normal. He underwent mixed-meal tolerance tests with a high carbohydrate load (Enfamil) both by mouth and by G-tube, which did not elicit the characteristic rise in lactate levels seen in GSD0. However, CGM profiles revealed postprandial hyperglycemia (serum BG 180-250 mg/dL) within the first hour of feeds, followed by a drop in glucose levels (serum BG 50-60 mg/dL) about 2 hours later (Fig. 1A). He completed a second nuclear medicine gastric emptying study that was normal.
Table 2. Critical Labs, Glucagon Stimulation Test, and Additional Labs
Patient Timing of critical labs Critical labsa Glucagon stimulation testb Diabetes screening Cosyntropin stimulation testd
1 16 hours into fast Serum BG 46 mg/dL Blunted BG rise: HgbA1C 4.8% Cortisol:
Insulin < 1.0 ng/mL 0 min = 50 mg/dL Negative β cell 0 min = 10 ug/dL
C-peptide 0.1 ng/mL 40 min = 55 mg/dL Autoantibodiesc 60 min = 27 ug/dL
βHB 4.12 mmol/L
FFA 1.12 mmol/L
Cortisol 2 (4-19 ug/dL)
GH 6.1 (2-10 ng/mL)
2 4 hours after a 50 g glucose load Serum BG 31mg/dL Stimulated BG rise: HbA1c 4.7% Cortisol:
Insulin 1.9 mU/L 0 min = 50 mg/dL 0 min = 2 ug/dL
C-peptide 1.7 ng/mL 27 min = 126 mg/dL 60 min = 27 ug/dL
βHB 0.12 mmol/L
FFA 0.32 mmol/L
Cortisol 4 (4-19 ug/dL)
GH 6.0 (2-10 ng/mL)
3 2 hours after bolus G-tube feed Serum BG 15 mg/dL Stimulated BG rise: HbA1c 4.8% Cortisol:
Insulin 35.9 mU/L 0 min = 15 mg/dL 0 min = 10 ug/dL
βHB 0.15 mmol/L 28 min = 108 mg/dL 60 min = 35 ug/dL
FFA 0.1 mmol/L
Cortisol 2 (4-22 ug/dL)
Abbreviations: BG, blood glucose; CGM, continuous glucose monitoring; FFA, free fatty acids; GH, growth hormone; βHB, β hydroxybutyrate; min, minute
aReference ranges for critical labs obtained from Ferrara et al., 2016 [5]. Hyperinsulinism is defined as detectable insulin (>0 mU/L), detectable C-peptide ≥ 0.5 ng/ml, suppressed βHB < 1.8 mM, and suppressed FFA < 1.7mM.
b Stimulated rise for a glucagon stimulation test is a rise in BG ≥ 30mg/dl in 30 minutes [5]
cβ-cell autoantibodies (insulin autoantibody, islet cell antibody, islet cell antigen 512 antibody, zinc transport 8 antibody, and GAD-65 autoantibody) were run at Quest Diagnostics Nichols Institute, San Juan Capistrano, CA solely for the purpose of patient clinical care.
dCosyntropin stimulation test reference range is a 60 min cortisol value of ≥18 ug/dL [6].
Figure 1. Continuous glucose monitoring (CGM) profiles. A-D, Continuous glucose monitoring (CGM) profiles with feeds. Arrows indicate time of meals. A, Patient 1 CGM profile with hyperglycemia followed by hypoglycemia after oral feeds (CGM software: Tidepool). B, Patient 2 CGM profile with hyperglycemia followed by hypoglycemia after oral feeds (CGM software: Tidepool). C, Patient 3 CGM profile with hyperglycemia followed by hypoglycemia after bolus G-tube feeds (CGM software: Tidepool). D, Patient 3 CGM profile after cornstarch and feeding manipulation, with normoglycemia (CGM software: Tidepool).
Despite the imaging study results, his clinical picture and CGM profiles showing a pattern of glycemic dysregulation were most consistent with postprandial hypoglycemia due to late dumping syndrome. Dietary modifications with the addition of complex carbohydrates and more frequent, smaller enteral feeds were not tolerated. Acarbose prior to large meals was initiated with improved blood glucose values. He was discharged home with a CGM device and instructions to treat hypoglycemia with small volumes of juice. By 10 months old, he required an increase in his acarbose dose prior to meals due to persistent hypoglycemia. His G-tube was removed at 22 months of age, and he had no further episodes of hypoglycemia and his dumping syndrome was presumed to be resolved.
Patient 2
An 8-month-old term male infant with a history of chronic aspiration, severe GERD, and hypotonia status post-Nissen fundoplication and G-tube placement was hospitalized with feeding intolerance, dehydration, and asymptomatic hypoglycemia (serum BG 43 mg/dL). Physical exam showed mild hypotonia, no midline defects, and a normal phallus. Loose stools occurred after bolus G-tube feeds. The hypoglycemia was attributed to prolonged fasting, and the patient was discharged home with instructions to treat hypoglycemia with small volumes of juice. At home, he continued to have asymptomatic hypoglycemia, with self-monitoring blood glucose levels as low as 40 mg/dL.
At age 12 months, he was readmitted for workup of ongoing hypoglycemia. Intermittent blood glucose monitoring did not capture the timing of hypoglycemia in relation to feeds, so a CGM device was placed. Enteral feeds were changed to continuous overnight with intermittent boluses during the day. Metabolic workup and single nucleotide polymorphism (SNP) array were unremarkable. An upper gastrointestinal (GI) study showed the G-tube balloon in the antrum but away from the pylorus. He did not develop hypoglycemia during an 11-hour fast. Four hours after a 50-gram glucose load was given via G-tube, his serum blood glucose fell to 31 mg/dL with associated tachycardia, sweating, and tremors. Critical labs showed hyperinsulinemic hypoglycemia with a lack of counter-regulatory cortisol rise, though subsequent cosyntropin stimulation test was normal (Table 2). His postprandial hyperinsulinemic hypoglycemia was attributed to late dumping syndrome.
Subsequent monitoring with CGM revealed that hypoglycemia persisted after bolus G-tube feeds. A gastric emptying study showed severely delayed gastric emptying (liquid half-emptying time of 370 minutes; upper limit of normal 45-60 minutes). Acarbose and cornstarch prior to bolus feeds were unsuccessful in preventing hypoglycemia. Erythromycin was trialed for gastroparesis but discontinued when it worsened hypoglycemia. Feeds were lengthened to continuous enteral feeds, which improved blood glucose values.
At 19 months old, he was switched to a gastrojejunostomy (GJ) tube due to multiple G-tube malfunctions and gastroparesis. CGM was used to guide feeding adjustments. Continuous G-tube feeds, with short breaks, were transitioned to J-tube feeds. After oral intake of 5 to 10 g of carbohydrates was introduced, CGM trends revealed dysglycemia classic for late dumping syndrome, with postprandial hyperglycemia (180-300 mg/dL) about 1 hour after oral intake followed by hypoglycemia (48-65 mg/dL) 3 hours later (Fig. 1B). Occasional hypoglycemia after oral intake is ongoing and is treated with a small volume of cherry syrup via G-tube.
Patient 3
A 13-month-old male with repaired esophageal atresia and distal tracheoesophageal fistula type C requiring esophageal dilations for strictures and G-tube placement for oral aversion presented with a hypoglycemic seizure. The serum BG was noted to be 17 mg/dL and occurred 2 hours after a bolus G-tube feed. He had previously been evaluated at 8 and 9 months of age for seizure-like activity. Video electroencephalography was unremarkable and the episodes were attributed to Sandifer syndrome, a manifestation of GERD characterized by abnormal and dystonic movements of the head, neck, and trunk [7]. During one admission, he had a serum BG of 52 mg/dL and follow-up POC BG of 89 mg/dL.
During this admission at 13 months of age, intermittent blood glucose monitoring did not capture his asymptomatic hypoglycemia episodes, so a CGM device was placed. Abdominal radiograph, upper GI series, gastric emptying scan, and glucose tolerance testing did not fulfill existing diagnostic criteria for either early or late dumping syndrome [1]. CGM profiles revealed hyperglycemia to BG 200 to 300 mg/dL at 1 hour after bolus feeds, followed by hypoglycemia 2 hours after feeds (Fig. 1C). CGM expedited the attainment of a critical sample, notable for hyperinsulinemic hypoglycemia to serum BG 15 mg/dL with a lack of counter-regulatory cortisol rise, and glucagon stimulation test with a robust glycemic response (Table 2). A subsequent cosyntropin stimulation test was normal (Table 2). A fasting study confirmed physiologic, ketotic hypoglycemia after 16.5 hours, and his postprandial, hyperinsulinemic hypoglycemia was attributed to late dumping syndrome. CGM showed normoglycemia on smaller daytime bolus enteral feeds and overnight continuous enteral feeds (Fig. 1D), and the child was discharged home with a glucometer and instructions to treat hypoglycemia with small volumes of juice.
He was subsequently readmitted for feeding adjustments, and CGM safely guided these changes. At 18 months of age, cornstarch was added to daytime intermittent bolus feeds. After several months, his mother discontinued cornstarch due to normal POC BGs at home. At 29 months of age, CGM again revealed postprandial hyperglycemia to BG 200 to 300 mg/dL followed by asymptomatic hypoglycemia to BG 35 mg/dL at 1.5 to 2 hours after feeds, which would have likely been missed with intermittent home POC BG monitoring. He was able to maintain normoglycemia with oral feeds, and his enteral feeds were discontinued. At 32 months of age, his G-tube was removed, and he experienced no further hypoglycemic episodes or seizure-like activity.
Discussion
Postprandial hypoglycemia due to late dumping syndrome can occur after Nissen fundoplication and other gastric surgeries, but it is difficult to detect in young children. Previous authors have encouraged a low threshold for glucose monitoring if a child has feeding difficulties after gastric procedures, citing the wide variability in clinical presentations of dumping syndrome in children [8, 9]. After initiating an asymptomatic hypoglycemia screening program, one institution noted that nearly a quarter of children who underwent fundoplication developed postprandial hypoglycemia within one week. Only half of these children exhibited other symptoms of dumping syndrome [10].
We have presented cases of 3 young children who required multiple hospitalizations to diagnose and manage postprandial hypoglycemia, which was ultimately attributed to late dumping syndrome. Prior to being diagnosed with dumping syndrome, one child presented with seizures, which were misattributed to Sandifer syndrome. The seizures were likely caused by undiagnosed hypoglycemia. In each case, there was evidence of asymptomatic hypoglycemia and blunted counter-regulatory hormonal responses, with low counter-regulatory cortisol but subsequently normal cosyntropin stimulation testing. These observations highlight the challenges in diagnosing late dumping syndrome in a younger pediatric population, particularly infants and toddlers, who have limited ability to communicate. Parents and health care providers may miss subtle signs of hypoglycemia, even with intermittent glucose monitoring. Further complicating this scenario is the rapid development of hypoglycemia unawareness, in which profound and recurrent hypoglycemia blunts neuroglycopenic symptoms and counter-regulatory responses [3, 11]. Thus, based on the prior experiences of other institutions, [8–10] and the cases described herein, we suspect that postprandial hypoglycemia due to late dumping syndrome is underdiagnosed, and is more prevalent than previously recognized. Even when diagnosed, we suspect that there are significant delays in diagnosis, as noted with our case series.
In approaching the diagnosis, one must consider the differences between early and late dumping syndrome. Closely monitoring for the timing or presence of vasomotor and gastrointestinal symptoms (early dumping syndrome) or reactive hypoglycemia (late dumping syndrome) in the hours following a glucose load can aid diagnosis [12]. Adult consensus guidelines define an increase in hematocrit >3% or a rise in heart rate >10 beats per minute by 30 minutes after the start of a modified oral glucose tolerance test as diagnostic of early dumping syndrome. The development of a blood glucose level <50 mg/dL, about 1 to 3 hours after the glucose load, is diagnostic of late dumping syndrome [13]. In our cases, none of the patients displayed signs or symptoms of gastrointestinal upset or vasomotor symptoms that would be characteristic of early dumping syndrome. This highlights the importance of understanding that early and late dumping syndrome can occur in isolation of one another.
Furthermore, as pathophysiology of late dumping syndrome is hormonal, imaging modalities may not detect the diagnosis [12]. Reactive hypoglycemia is triggered by accelerated delivery of a carbohydrate load into the small intestine, with resultant hormonal dysregulation, including hyperglycemia and a hyperinsulinemic response followed by a precipitous fall in serum glucose [2]. In all of our cases, gastric imaging studies, including gastric emptying studies, upper GI studies, and nuclear medicine studies, had low diagnostic yield. The imaging studies were either normal or displayed results contrary to what would be expected in dumping syndrome. Thus, the pursuit of multiple imaging studies led to a delay in diagnosis, extension of hospitalization, and heightened family frustration.
Given the dynamic nature of glycemic changes postprandially during dumping syndrome, it is not surprising that intermittent use of glucometer testing failed to identify the pattern of glycemic excursions characteristic of dumping syndrome in our cases. CGM was essential for diagnosis of late dumping syndrome by revealing the dynamic glycemic excursion, with hyperglycemia following by hypoglycemia, after feeds (Fig. 1, A-C). Critical samples showing a hyperinsulinemic response after a glucose load, in 2 of the cases, corroborated this diagnosis (Table 2).
CGM was also useful to guide therapeutic interventions that included feeding manipulations, cornstarch, and acarbose. First-line treatment of postprandial hypoglycemia due to late dumping syndrome includes the use of dietary modification with more frequent or continuous feeds and dietary supplementation with fiber, cornstarch, or gelling agents. Second-line therapy is acarbose, an alpha glucosidase inhibitor that blunts carbohydrate breakdown. Somatostatin analogues are reserved for patients who do not respond to dietary adjustments and acarbose [14]. CGM enabled safe modification of the feeding and medication regimens of the 3 patients described herein (Fig. 1D). CGM also enabled families to identify and intervene on hypoglycemic episodes that may have gone unnoticed with traditional POC glucometer use. In the event of hypoglycemia, families were instructed to give a small quantity of rapid-acting glucose. Early hypoglycemia intervention is particularly important in young children as recurrent hypoglycemia is associated with poor long-term neurocognitive outcomes [15].Thus, our cases contribute to a growing body of evidence that supports the use of CGM to diagnose and manage reactive hypoglycemia [16-19].
We conclude that because of the variable results in imaging studies and the rapid development of hypoglycemia unawareness in children, CGM should be the first line in evaluating children that may have hypoglycemia after gastric procedures. Abnormal blood glucoses may be missed with intermittent glucometer checks, and postprandial hypoglycemia in children with a history of gastric surgery is likely underdiagnosed. Clinicians should maintain a high index of suspicion for dumping syndrome when evaluating children with a history of gastric surgeries, even if the child exhibits no or few clinical symptoms. CGM can help with earlier diagnosis of dumping syndrome and can reveal the characteristic pattern of glycemic dysregulation. Furthermore, it can be used to efficiently evaluate the effectiveness of various treatments and feeding regimens.
Acknowledgments
Financial support: Research reported in this publication was supported by the National Institute of Diabetes and Digestive and Kidney Diseases (award number T32DK007161 awarded to HC, AH, and JYL) and the Eunice Kennedy Shriver National Institute of Child Health & Human Development (award number F32HD098763 awarded to JYL) of the National Institutes of Health. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.
Abbreviations
BG blood glucose
CGM continuous glucose monitoring
GERD gastroesophageal reflux disease
GI gastrointestinal
GLP-1 glucagon-like peptide-1
G-tube gastrostomy tube
POC point-of-care
Additional Information
Disclosures: H.C., F.A., A.H., J.Y.L., and S.E.G. have no relevant financial interests to disclose.
Data Availability
Data sharing is not applicable to this article as no datasets were generated or analyzed during the current study. | ACARBOSE, DEXTROSE, ERYTHROMYCIN | DrugsGivenReaction | CC BY-NC-ND | 33506160 | 20,257,580 | 2021-03-01 |
What was the administration route of drug 'DEXTROSE'? | Continuous Glucose Monitoring to Diagnose Hypoglycemia Due to Late Dumping Syndrome in Children After Gastric Surgeries.
Gastrostomy tubes (G-tubes) and Nissen fundoplication are common surgical interventions for feeding difficulties and gastroesophageal reflux disease in children. A potential yet often missed, complication of these procedures is dumping syndrome. We present 3 pediatric patients with postprandial hypoglycemia due to late dumping syndrome after gastric surgeries. All patients received gastrostomy tubes for feeding intolerance: 2 had Nissen fundoplication for gastroesophageal reflux disease, and 1 had tracheoesophageal repair. All patients underwent multiple imaging studies in an to attempt to diagnose dumping syndrome. Continuous glucose monitoring (CGM) was essential for detecting asymptomatic hypoglycemia and glycemic excursions occurring with feeds that would have gone undetected with point-of-care (POC) blood glucose checks. CGM was also used to monitor the effectiveness of treatment strategies and drive treatment plans. These cases highlight the utility of CGM in diagnosing postprandial hypoglycemia due to late dumping syndrome, which is infrequently diagnosed by imaging studies and intermittent POC blood glucose measurements.
Gastrostomy tubes (G-tubes) and Nissen fundoplications are increasingly employed to treat feeding intolerance and gastroesophageal reflux disease (GERD) in children. Removing the barrier function of the pylorus or reducing gastric volume can lead to undigested food rapidly entering the small intestine, which can result in dumping syndrome [1]. The symptoms of dumping syndrome are classified as early and late, which can occur together or in isolation. Early dumping syndrome typically occurs within the first hour after eating with gastrointestinal and vasomotor symptoms including nausea, vomiting, abdominal cramping, sweating, tachycardia, and dizziness. Late dumping syndrome, also referred to as reactive or postprandial hyperinsulinemic hypoglycemia, typically occurs 1 to 3 hours after eating and manifests as hypoglycemia due to a hyperinsulinemic response. Exaggerated secretion of glucagon-like peptide 1 (GLP-1) has been implicated as a key mediator of postprandial hypoglycemia in late dumping syndrome [2].
The diagnosis of late dumping syndrome can be particularly elusive in children. The signs and symptoms may go unrecognized, especially in younger children. In addition, recurrent episodes of hypoglycemia may result in hypoglycemia unawareness [3], compounding the challenges in making the diagnosis. Further complicating the diagnosis is the lack of consensus guidelines for diagnosing dumping syndrome in the pediatric population.
Herein, we present a case series of 3 children with postprandial hypoglycemia due to late dumping syndrome. Although imaging studies did not indicate dumping syndrome, continuous glucose monitoring (CGM) proved to be a useful adjunctive study for both the diagnosis and assessment of the effectiveness of therapy.
Case Series
The patients presented to our institution between 2015 and 2019. Table 1 summarizes the clinical characteristics of the patients. Two of the patients received a Nissen fundoplication for GERD and one patient underwent gastroesophageal repair for tracheoesophageal fistula. All patients had feeding intolerance manifested by frequent vomiting and aspiration, for which a G-tube was placed. CGM (Dexcom; San Diego, California) devices were placed on the patients to better evaluate the glycemic patterns associated with feeds. Dexcom G4, G5, and G6 devices were used and calibrated per industry recommendations. The data stored by the CGM devices were uploaded to Dexcom Clarity or Tidepool, a web-based cloud software system for collecting and visualizing diabetes device data [4].
Table 1. Patient Characteristics
Patient Age at presentation (months) Past medical history Surgery (age at surgery) Feeding regimen at presentation Diagnostic test Imaging studies (result) Glucose monitoring Treatment
1 8-9 FTT, GERD G-tube and Nissen fundoplication (6 months) Oral and enteral MMTT Nuclear medicine study × 2 (normal) Inpatient: CGM Outpatient: Glucometer Acarbose prior to meals
2 9 Chronic aspiration, hypotonia, GERD G-tube and Nissen fundoplication (7 months) Enteral OGTT Gastric emptying study × 2 (severely delayed gastric emptying) Inpatient: CGM Feeding manipulation
Outpatient: CGM Acarbose prior to bolus feeds unsuccessful
Upper GI study (normal) Cornstarch with bolus feeds unsuccessful
3 13 Esophageal atresia and distal tracheoesophageal fistula (EA-TEF type C) G-tube and tracheoesophageal repair and dilations (0 months) Enteral MMTT Gastric emptying study (normal) Inpatient: CGM Feeding manipulation
Outpatient: Glucometer Cornstarch with bolus feeds
Abbreviations: CGM, continuous glucose monitoring; FTT, failure to thrive; MMT, mixed-meal tolerance test; OGTT, oral glucose tolerance test.
Patient 1
A 9-month-old full-term male infant with a history of poor growth and severe GERD status post-Nissen fundoplication and G-tube placement presented with labile blood glucoses (BG) ranging from 50 to 200 mg/dL. Loose stools occurred after G-tube feeds and, in retrospect, the child seemed fatigued after feeds. He had a previous hospitalization at age 8 months for hypoglycemia; however, no critical sample was captured, and a nuclear medicine gastric emptying study was normal.
He was again hospitalized for extensive workup of glucose lability at 9 months of age. Physical exam was unremarkable with an alert and interactive infant with normal phallus and no midline defects. It was difficult to capture the timing of the hypoglycemia with POC blood glucose monitoring, so a CGM device was placed. He underwent a 16-hour fast and then demonstrated physiologic, ketotic hypoglycemia and a blunted glucose response to glucagon, with a lack of counter-regulatory cortisol rise (Table 2). Subsequent anterior pituitary workup, including a cosyntropin stimulation test, was normal. Given the postprandial hyperglycemia and hypoglycemia, there was suspicion for glycogen storage disease type 0 (GSD0). Liver ultrasound was normal. He underwent mixed-meal tolerance tests with a high carbohydrate load (Enfamil) both by mouth and by G-tube, which did not elicit the characteristic rise in lactate levels seen in GSD0. However, CGM profiles revealed postprandial hyperglycemia (serum BG 180-250 mg/dL) within the first hour of feeds, followed by a drop in glucose levels (serum BG 50-60 mg/dL) about 2 hours later (Fig. 1A). He completed a second nuclear medicine gastric emptying study that was normal.
Table 2. Critical Labs, Glucagon Stimulation Test, and Additional Labs
Patient Timing of critical labs Critical labsa Glucagon stimulation testb Diabetes screening Cosyntropin stimulation testd
1 16 hours into fast Serum BG 46 mg/dL Blunted BG rise: HgbA1C 4.8% Cortisol:
Insulin < 1.0 ng/mL 0 min = 50 mg/dL Negative β cell 0 min = 10 ug/dL
C-peptide 0.1 ng/mL 40 min = 55 mg/dL Autoantibodiesc 60 min = 27 ug/dL
βHB 4.12 mmol/L
FFA 1.12 mmol/L
Cortisol 2 (4-19 ug/dL)
GH 6.1 (2-10 ng/mL)
2 4 hours after a 50 g glucose load Serum BG 31mg/dL Stimulated BG rise: HbA1c 4.7% Cortisol:
Insulin 1.9 mU/L 0 min = 50 mg/dL 0 min = 2 ug/dL
C-peptide 1.7 ng/mL 27 min = 126 mg/dL 60 min = 27 ug/dL
βHB 0.12 mmol/L
FFA 0.32 mmol/L
Cortisol 4 (4-19 ug/dL)
GH 6.0 (2-10 ng/mL)
3 2 hours after bolus G-tube feed Serum BG 15 mg/dL Stimulated BG rise: HbA1c 4.8% Cortisol:
Insulin 35.9 mU/L 0 min = 15 mg/dL 0 min = 10 ug/dL
βHB 0.15 mmol/L 28 min = 108 mg/dL 60 min = 35 ug/dL
FFA 0.1 mmol/L
Cortisol 2 (4-22 ug/dL)
Abbreviations: BG, blood glucose; CGM, continuous glucose monitoring; FFA, free fatty acids; GH, growth hormone; βHB, β hydroxybutyrate; min, minute
aReference ranges for critical labs obtained from Ferrara et al., 2016 [5]. Hyperinsulinism is defined as detectable insulin (>0 mU/L), detectable C-peptide ≥ 0.5 ng/ml, suppressed βHB < 1.8 mM, and suppressed FFA < 1.7mM.
b Stimulated rise for a glucagon stimulation test is a rise in BG ≥ 30mg/dl in 30 minutes [5]
cβ-cell autoantibodies (insulin autoantibody, islet cell antibody, islet cell antigen 512 antibody, zinc transport 8 antibody, and GAD-65 autoantibody) were run at Quest Diagnostics Nichols Institute, San Juan Capistrano, CA solely for the purpose of patient clinical care.
dCosyntropin stimulation test reference range is a 60 min cortisol value of ≥18 ug/dL [6].
Figure 1. Continuous glucose monitoring (CGM) profiles. A-D, Continuous glucose monitoring (CGM) profiles with feeds. Arrows indicate time of meals. A, Patient 1 CGM profile with hyperglycemia followed by hypoglycemia after oral feeds (CGM software: Tidepool). B, Patient 2 CGM profile with hyperglycemia followed by hypoglycemia after oral feeds (CGM software: Tidepool). C, Patient 3 CGM profile with hyperglycemia followed by hypoglycemia after bolus G-tube feeds (CGM software: Tidepool). D, Patient 3 CGM profile after cornstarch and feeding manipulation, with normoglycemia (CGM software: Tidepool).
Despite the imaging study results, his clinical picture and CGM profiles showing a pattern of glycemic dysregulation were most consistent with postprandial hypoglycemia due to late dumping syndrome. Dietary modifications with the addition of complex carbohydrates and more frequent, smaller enteral feeds were not tolerated. Acarbose prior to large meals was initiated with improved blood glucose values. He was discharged home with a CGM device and instructions to treat hypoglycemia with small volumes of juice. By 10 months old, he required an increase in his acarbose dose prior to meals due to persistent hypoglycemia. His G-tube was removed at 22 months of age, and he had no further episodes of hypoglycemia and his dumping syndrome was presumed to be resolved.
Patient 2
An 8-month-old term male infant with a history of chronic aspiration, severe GERD, and hypotonia status post-Nissen fundoplication and G-tube placement was hospitalized with feeding intolerance, dehydration, and asymptomatic hypoglycemia (serum BG 43 mg/dL). Physical exam showed mild hypotonia, no midline defects, and a normal phallus. Loose stools occurred after bolus G-tube feeds. The hypoglycemia was attributed to prolonged fasting, and the patient was discharged home with instructions to treat hypoglycemia with small volumes of juice. At home, he continued to have asymptomatic hypoglycemia, with self-monitoring blood glucose levels as low as 40 mg/dL.
At age 12 months, he was readmitted for workup of ongoing hypoglycemia. Intermittent blood glucose monitoring did not capture the timing of hypoglycemia in relation to feeds, so a CGM device was placed. Enteral feeds were changed to continuous overnight with intermittent boluses during the day. Metabolic workup and single nucleotide polymorphism (SNP) array were unremarkable. An upper gastrointestinal (GI) study showed the G-tube balloon in the antrum but away from the pylorus. He did not develop hypoglycemia during an 11-hour fast. Four hours after a 50-gram glucose load was given via G-tube, his serum blood glucose fell to 31 mg/dL with associated tachycardia, sweating, and tremors. Critical labs showed hyperinsulinemic hypoglycemia with a lack of counter-regulatory cortisol rise, though subsequent cosyntropin stimulation test was normal (Table 2). His postprandial hyperinsulinemic hypoglycemia was attributed to late dumping syndrome.
Subsequent monitoring with CGM revealed that hypoglycemia persisted after bolus G-tube feeds. A gastric emptying study showed severely delayed gastric emptying (liquid half-emptying time of 370 minutes; upper limit of normal 45-60 minutes). Acarbose and cornstarch prior to bolus feeds were unsuccessful in preventing hypoglycemia. Erythromycin was trialed for gastroparesis but discontinued when it worsened hypoglycemia. Feeds were lengthened to continuous enteral feeds, which improved blood glucose values.
At 19 months old, he was switched to a gastrojejunostomy (GJ) tube due to multiple G-tube malfunctions and gastroparesis. CGM was used to guide feeding adjustments. Continuous G-tube feeds, with short breaks, were transitioned to J-tube feeds. After oral intake of 5 to 10 g of carbohydrates was introduced, CGM trends revealed dysglycemia classic for late dumping syndrome, with postprandial hyperglycemia (180-300 mg/dL) about 1 hour after oral intake followed by hypoglycemia (48-65 mg/dL) 3 hours later (Fig. 1B). Occasional hypoglycemia after oral intake is ongoing and is treated with a small volume of cherry syrup via G-tube.
Patient 3
A 13-month-old male with repaired esophageal atresia and distal tracheoesophageal fistula type C requiring esophageal dilations for strictures and G-tube placement for oral aversion presented with a hypoglycemic seizure. The serum BG was noted to be 17 mg/dL and occurred 2 hours after a bolus G-tube feed. He had previously been evaluated at 8 and 9 months of age for seizure-like activity. Video electroencephalography was unremarkable and the episodes were attributed to Sandifer syndrome, a manifestation of GERD characterized by abnormal and dystonic movements of the head, neck, and trunk [7]. During one admission, he had a serum BG of 52 mg/dL and follow-up POC BG of 89 mg/dL.
During this admission at 13 months of age, intermittent blood glucose monitoring did not capture his asymptomatic hypoglycemia episodes, so a CGM device was placed. Abdominal radiograph, upper GI series, gastric emptying scan, and glucose tolerance testing did not fulfill existing diagnostic criteria for either early or late dumping syndrome [1]. CGM profiles revealed hyperglycemia to BG 200 to 300 mg/dL at 1 hour after bolus feeds, followed by hypoglycemia 2 hours after feeds (Fig. 1C). CGM expedited the attainment of a critical sample, notable for hyperinsulinemic hypoglycemia to serum BG 15 mg/dL with a lack of counter-regulatory cortisol rise, and glucagon stimulation test with a robust glycemic response (Table 2). A subsequent cosyntropin stimulation test was normal (Table 2). A fasting study confirmed physiologic, ketotic hypoglycemia after 16.5 hours, and his postprandial, hyperinsulinemic hypoglycemia was attributed to late dumping syndrome. CGM showed normoglycemia on smaller daytime bolus enteral feeds and overnight continuous enteral feeds (Fig. 1D), and the child was discharged home with a glucometer and instructions to treat hypoglycemia with small volumes of juice.
He was subsequently readmitted for feeding adjustments, and CGM safely guided these changes. At 18 months of age, cornstarch was added to daytime intermittent bolus feeds. After several months, his mother discontinued cornstarch due to normal POC BGs at home. At 29 months of age, CGM again revealed postprandial hyperglycemia to BG 200 to 300 mg/dL followed by asymptomatic hypoglycemia to BG 35 mg/dL at 1.5 to 2 hours after feeds, which would have likely been missed with intermittent home POC BG monitoring. He was able to maintain normoglycemia with oral feeds, and his enteral feeds were discontinued. At 32 months of age, his G-tube was removed, and he experienced no further hypoglycemic episodes or seizure-like activity.
Discussion
Postprandial hypoglycemia due to late dumping syndrome can occur after Nissen fundoplication and other gastric surgeries, but it is difficult to detect in young children. Previous authors have encouraged a low threshold for glucose monitoring if a child has feeding difficulties after gastric procedures, citing the wide variability in clinical presentations of dumping syndrome in children [8, 9]. After initiating an asymptomatic hypoglycemia screening program, one institution noted that nearly a quarter of children who underwent fundoplication developed postprandial hypoglycemia within one week. Only half of these children exhibited other symptoms of dumping syndrome [10].
We have presented cases of 3 young children who required multiple hospitalizations to diagnose and manage postprandial hypoglycemia, which was ultimately attributed to late dumping syndrome. Prior to being diagnosed with dumping syndrome, one child presented with seizures, which were misattributed to Sandifer syndrome. The seizures were likely caused by undiagnosed hypoglycemia. In each case, there was evidence of asymptomatic hypoglycemia and blunted counter-regulatory hormonal responses, with low counter-regulatory cortisol but subsequently normal cosyntropin stimulation testing. These observations highlight the challenges in diagnosing late dumping syndrome in a younger pediatric population, particularly infants and toddlers, who have limited ability to communicate. Parents and health care providers may miss subtle signs of hypoglycemia, even with intermittent glucose monitoring. Further complicating this scenario is the rapid development of hypoglycemia unawareness, in which profound and recurrent hypoglycemia blunts neuroglycopenic symptoms and counter-regulatory responses [3, 11]. Thus, based on the prior experiences of other institutions, [8–10] and the cases described herein, we suspect that postprandial hypoglycemia due to late dumping syndrome is underdiagnosed, and is more prevalent than previously recognized. Even when diagnosed, we suspect that there are significant delays in diagnosis, as noted with our case series.
In approaching the diagnosis, one must consider the differences between early and late dumping syndrome. Closely monitoring for the timing or presence of vasomotor and gastrointestinal symptoms (early dumping syndrome) or reactive hypoglycemia (late dumping syndrome) in the hours following a glucose load can aid diagnosis [12]. Adult consensus guidelines define an increase in hematocrit >3% or a rise in heart rate >10 beats per minute by 30 minutes after the start of a modified oral glucose tolerance test as diagnostic of early dumping syndrome. The development of a blood glucose level <50 mg/dL, about 1 to 3 hours after the glucose load, is diagnostic of late dumping syndrome [13]. In our cases, none of the patients displayed signs or symptoms of gastrointestinal upset or vasomotor symptoms that would be characteristic of early dumping syndrome. This highlights the importance of understanding that early and late dumping syndrome can occur in isolation of one another.
Furthermore, as pathophysiology of late dumping syndrome is hormonal, imaging modalities may not detect the diagnosis [12]. Reactive hypoglycemia is triggered by accelerated delivery of a carbohydrate load into the small intestine, with resultant hormonal dysregulation, including hyperglycemia and a hyperinsulinemic response followed by a precipitous fall in serum glucose [2]. In all of our cases, gastric imaging studies, including gastric emptying studies, upper GI studies, and nuclear medicine studies, had low diagnostic yield. The imaging studies were either normal or displayed results contrary to what would be expected in dumping syndrome. Thus, the pursuit of multiple imaging studies led to a delay in diagnosis, extension of hospitalization, and heightened family frustration.
Given the dynamic nature of glycemic changes postprandially during dumping syndrome, it is not surprising that intermittent use of glucometer testing failed to identify the pattern of glycemic excursions characteristic of dumping syndrome in our cases. CGM was essential for diagnosis of late dumping syndrome by revealing the dynamic glycemic excursion, with hyperglycemia following by hypoglycemia, after feeds (Fig. 1, A-C). Critical samples showing a hyperinsulinemic response after a glucose load, in 2 of the cases, corroborated this diagnosis (Table 2).
CGM was also useful to guide therapeutic interventions that included feeding manipulations, cornstarch, and acarbose. First-line treatment of postprandial hypoglycemia due to late dumping syndrome includes the use of dietary modification with more frequent or continuous feeds and dietary supplementation with fiber, cornstarch, or gelling agents. Second-line therapy is acarbose, an alpha glucosidase inhibitor that blunts carbohydrate breakdown. Somatostatin analogues are reserved for patients who do not respond to dietary adjustments and acarbose [14]. CGM enabled safe modification of the feeding and medication regimens of the 3 patients described herein (Fig. 1D). CGM also enabled families to identify and intervene on hypoglycemic episodes that may have gone unnoticed with traditional POC glucometer use. In the event of hypoglycemia, families were instructed to give a small quantity of rapid-acting glucose. Early hypoglycemia intervention is particularly important in young children as recurrent hypoglycemia is associated with poor long-term neurocognitive outcomes [15].Thus, our cases contribute to a growing body of evidence that supports the use of CGM to diagnose and manage reactive hypoglycemia [16-19].
We conclude that because of the variable results in imaging studies and the rapid development of hypoglycemia unawareness in children, CGM should be the first line in evaluating children that may have hypoglycemia after gastric procedures. Abnormal blood glucoses may be missed with intermittent glucometer checks, and postprandial hypoglycemia in children with a history of gastric surgery is likely underdiagnosed. Clinicians should maintain a high index of suspicion for dumping syndrome when evaluating children with a history of gastric surgeries, even if the child exhibits no or few clinical symptoms. CGM can help with earlier diagnosis of dumping syndrome and can reveal the characteristic pattern of glycemic dysregulation. Furthermore, it can be used to efficiently evaluate the effectiveness of various treatments and feeding regimens.
Acknowledgments
Financial support: Research reported in this publication was supported by the National Institute of Diabetes and Digestive and Kidney Diseases (award number T32DK007161 awarded to HC, AH, and JYL) and the Eunice Kennedy Shriver National Institute of Child Health & Human Development (award number F32HD098763 awarded to JYL) of the National Institutes of Health. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.
Abbreviations
BG blood glucose
CGM continuous glucose monitoring
GERD gastroesophageal reflux disease
GI gastrointestinal
GLP-1 glucagon-like peptide-1
G-tube gastrostomy tube
POC point-of-care
Additional Information
Disclosures: H.C., F.A., A.H., J.Y.L., and S.E.G. have no relevant financial interests to disclose.
Data Availability
Data sharing is not applicable to this article as no datasets were generated or analyzed during the current study. | Other | DrugAdministrationRoute | CC BY-NC-ND | 33506160 | 20,333,661 | 2021-03-01 |
What was the outcome of reaction 'Hypoglycaemia'? | Continuous Glucose Monitoring to Diagnose Hypoglycemia Due to Late Dumping Syndrome in Children After Gastric Surgeries.
Gastrostomy tubes (G-tubes) and Nissen fundoplication are common surgical interventions for feeding difficulties and gastroesophageal reflux disease in children. A potential yet often missed, complication of these procedures is dumping syndrome. We present 3 pediatric patients with postprandial hypoglycemia due to late dumping syndrome after gastric surgeries. All patients received gastrostomy tubes for feeding intolerance: 2 had Nissen fundoplication for gastroesophageal reflux disease, and 1 had tracheoesophageal repair. All patients underwent multiple imaging studies in an to attempt to diagnose dumping syndrome. Continuous glucose monitoring (CGM) was essential for detecting asymptomatic hypoglycemia and glycemic excursions occurring with feeds that would have gone undetected with point-of-care (POC) blood glucose checks. CGM was also used to monitor the effectiveness of treatment strategies and drive treatment plans. These cases highlight the utility of CGM in diagnosing postprandial hypoglycemia due to late dumping syndrome, which is infrequently diagnosed by imaging studies and intermittent POC blood glucose measurements.
Gastrostomy tubes (G-tubes) and Nissen fundoplications are increasingly employed to treat feeding intolerance and gastroesophageal reflux disease (GERD) in children. Removing the barrier function of the pylorus or reducing gastric volume can lead to undigested food rapidly entering the small intestine, which can result in dumping syndrome [1]. The symptoms of dumping syndrome are classified as early and late, which can occur together or in isolation. Early dumping syndrome typically occurs within the first hour after eating with gastrointestinal and vasomotor symptoms including nausea, vomiting, abdominal cramping, sweating, tachycardia, and dizziness. Late dumping syndrome, also referred to as reactive or postprandial hyperinsulinemic hypoglycemia, typically occurs 1 to 3 hours after eating and manifests as hypoglycemia due to a hyperinsulinemic response. Exaggerated secretion of glucagon-like peptide 1 (GLP-1) has been implicated as a key mediator of postprandial hypoglycemia in late dumping syndrome [2].
The diagnosis of late dumping syndrome can be particularly elusive in children. The signs and symptoms may go unrecognized, especially in younger children. In addition, recurrent episodes of hypoglycemia may result in hypoglycemia unawareness [3], compounding the challenges in making the diagnosis. Further complicating the diagnosis is the lack of consensus guidelines for diagnosing dumping syndrome in the pediatric population.
Herein, we present a case series of 3 children with postprandial hypoglycemia due to late dumping syndrome. Although imaging studies did not indicate dumping syndrome, continuous glucose monitoring (CGM) proved to be a useful adjunctive study for both the diagnosis and assessment of the effectiveness of therapy.
Case Series
The patients presented to our institution between 2015 and 2019. Table 1 summarizes the clinical characteristics of the patients. Two of the patients received a Nissen fundoplication for GERD and one patient underwent gastroesophageal repair for tracheoesophageal fistula. All patients had feeding intolerance manifested by frequent vomiting and aspiration, for which a G-tube was placed. CGM (Dexcom; San Diego, California) devices were placed on the patients to better evaluate the glycemic patterns associated with feeds. Dexcom G4, G5, and G6 devices were used and calibrated per industry recommendations. The data stored by the CGM devices were uploaded to Dexcom Clarity or Tidepool, a web-based cloud software system for collecting and visualizing diabetes device data [4].
Table 1. Patient Characteristics
Patient Age at presentation (months) Past medical history Surgery (age at surgery) Feeding regimen at presentation Diagnostic test Imaging studies (result) Glucose monitoring Treatment
1 8-9 FTT, GERD G-tube and Nissen fundoplication (6 months) Oral and enteral MMTT Nuclear medicine study × 2 (normal) Inpatient: CGM Outpatient: Glucometer Acarbose prior to meals
2 9 Chronic aspiration, hypotonia, GERD G-tube and Nissen fundoplication (7 months) Enteral OGTT Gastric emptying study × 2 (severely delayed gastric emptying) Inpatient: CGM Feeding manipulation
Outpatient: CGM Acarbose prior to bolus feeds unsuccessful
Upper GI study (normal) Cornstarch with bolus feeds unsuccessful
3 13 Esophageal atresia and distal tracheoesophageal fistula (EA-TEF type C) G-tube and tracheoesophageal repair and dilations (0 months) Enteral MMTT Gastric emptying study (normal) Inpatient: CGM Feeding manipulation
Outpatient: Glucometer Cornstarch with bolus feeds
Abbreviations: CGM, continuous glucose monitoring; FTT, failure to thrive; MMT, mixed-meal tolerance test; OGTT, oral glucose tolerance test.
Patient 1
A 9-month-old full-term male infant with a history of poor growth and severe GERD status post-Nissen fundoplication and G-tube placement presented with labile blood glucoses (BG) ranging from 50 to 200 mg/dL. Loose stools occurred after G-tube feeds and, in retrospect, the child seemed fatigued after feeds. He had a previous hospitalization at age 8 months for hypoglycemia; however, no critical sample was captured, and a nuclear medicine gastric emptying study was normal.
He was again hospitalized for extensive workup of glucose lability at 9 months of age. Physical exam was unremarkable with an alert and interactive infant with normal phallus and no midline defects. It was difficult to capture the timing of the hypoglycemia with POC blood glucose monitoring, so a CGM device was placed. He underwent a 16-hour fast and then demonstrated physiologic, ketotic hypoglycemia and a blunted glucose response to glucagon, with a lack of counter-regulatory cortisol rise (Table 2). Subsequent anterior pituitary workup, including a cosyntropin stimulation test, was normal. Given the postprandial hyperglycemia and hypoglycemia, there was suspicion for glycogen storage disease type 0 (GSD0). Liver ultrasound was normal. He underwent mixed-meal tolerance tests with a high carbohydrate load (Enfamil) both by mouth and by G-tube, which did not elicit the characteristic rise in lactate levels seen in GSD0. However, CGM profiles revealed postprandial hyperglycemia (serum BG 180-250 mg/dL) within the first hour of feeds, followed by a drop in glucose levels (serum BG 50-60 mg/dL) about 2 hours later (Fig. 1A). He completed a second nuclear medicine gastric emptying study that was normal.
Table 2. Critical Labs, Glucagon Stimulation Test, and Additional Labs
Patient Timing of critical labs Critical labsa Glucagon stimulation testb Diabetes screening Cosyntropin stimulation testd
1 16 hours into fast Serum BG 46 mg/dL Blunted BG rise: HgbA1C 4.8% Cortisol:
Insulin < 1.0 ng/mL 0 min = 50 mg/dL Negative β cell 0 min = 10 ug/dL
C-peptide 0.1 ng/mL 40 min = 55 mg/dL Autoantibodiesc 60 min = 27 ug/dL
βHB 4.12 mmol/L
FFA 1.12 mmol/L
Cortisol 2 (4-19 ug/dL)
GH 6.1 (2-10 ng/mL)
2 4 hours after a 50 g glucose load Serum BG 31mg/dL Stimulated BG rise: HbA1c 4.7% Cortisol:
Insulin 1.9 mU/L 0 min = 50 mg/dL 0 min = 2 ug/dL
C-peptide 1.7 ng/mL 27 min = 126 mg/dL 60 min = 27 ug/dL
βHB 0.12 mmol/L
FFA 0.32 mmol/L
Cortisol 4 (4-19 ug/dL)
GH 6.0 (2-10 ng/mL)
3 2 hours after bolus G-tube feed Serum BG 15 mg/dL Stimulated BG rise: HbA1c 4.8% Cortisol:
Insulin 35.9 mU/L 0 min = 15 mg/dL 0 min = 10 ug/dL
βHB 0.15 mmol/L 28 min = 108 mg/dL 60 min = 35 ug/dL
FFA 0.1 mmol/L
Cortisol 2 (4-22 ug/dL)
Abbreviations: BG, blood glucose; CGM, continuous glucose monitoring; FFA, free fatty acids; GH, growth hormone; βHB, β hydroxybutyrate; min, minute
aReference ranges for critical labs obtained from Ferrara et al., 2016 [5]. Hyperinsulinism is defined as detectable insulin (>0 mU/L), detectable C-peptide ≥ 0.5 ng/ml, suppressed βHB < 1.8 mM, and suppressed FFA < 1.7mM.
b Stimulated rise for a glucagon stimulation test is a rise in BG ≥ 30mg/dl in 30 minutes [5]
cβ-cell autoantibodies (insulin autoantibody, islet cell antibody, islet cell antigen 512 antibody, zinc transport 8 antibody, and GAD-65 autoantibody) were run at Quest Diagnostics Nichols Institute, San Juan Capistrano, CA solely for the purpose of patient clinical care.
dCosyntropin stimulation test reference range is a 60 min cortisol value of ≥18 ug/dL [6].
Figure 1. Continuous glucose monitoring (CGM) profiles. A-D, Continuous glucose monitoring (CGM) profiles with feeds. Arrows indicate time of meals. A, Patient 1 CGM profile with hyperglycemia followed by hypoglycemia after oral feeds (CGM software: Tidepool). B, Patient 2 CGM profile with hyperglycemia followed by hypoglycemia after oral feeds (CGM software: Tidepool). C, Patient 3 CGM profile with hyperglycemia followed by hypoglycemia after bolus G-tube feeds (CGM software: Tidepool). D, Patient 3 CGM profile after cornstarch and feeding manipulation, with normoglycemia (CGM software: Tidepool).
Despite the imaging study results, his clinical picture and CGM profiles showing a pattern of glycemic dysregulation were most consistent with postprandial hypoglycemia due to late dumping syndrome. Dietary modifications with the addition of complex carbohydrates and more frequent, smaller enteral feeds were not tolerated. Acarbose prior to large meals was initiated with improved blood glucose values. He was discharged home with a CGM device and instructions to treat hypoglycemia with small volumes of juice. By 10 months old, he required an increase in his acarbose dose prior to meals due to persistent hypoglycemia. His G-tube was removed at 22 months of age, and he had no further episodes of hypoglycemia and his dumping syndrome was presumed to be resolved.
Patient 2
An 8-month-old term male infant with a history of chronic aspiration, severe GERD, and hypotonia status post-Nissen fundoplication and G-tube placement was hospitalized with feeding intolerance, dehydration, and asymptomatic hypoglycemia (serum BG 43 mg/dL). Physical exam showed mild hypotonia, no midline defects, and a normal phallus. Loose stools occurred after bolus G-tube feeds. The hypoglycemia was attributed to prolonged fasting, and the patient was discharged home with instructions to treat hypoglycemia with small volumes of juice. At home, he continued to have asymptomatic hypoglycemia, with self-monitoring blood glucose levels as low as 40 mg/dL.
At age 12 months, he was readmitted for workup of ongoing hypoglycemia. Intermittent blood glucose monitoring did not capture the timing of hypoglycemia in relation to feeds, so a CGM device was placed. Enteral feeds were changed to continuous overnight with intermittent boluses during the day. Metabolic workup and single nucleotide polymorphism (SNP) array were unremarkable. An upper gastrointestinal (GI) study showed the G-tube balloon in the antrum but away from the pylorus. He did not develop hypoglycemia during an 11-hour fast. Four hours after a 50-gram glucose load was given via G-tube, his serum blood glucose fell to 31 mg/dL with associated tachycardia, sweating, and tremors. Critical labs showed hyperinsulinemic hypoglycemia with a lack of counter-regulatory cortisol rise, though subsequent cosyntropin stimulation test was normal (Table 2). His postprandial hyperinsulinemic hypoglycemia was attributed to late dumping syndrome.
Subsequent monitoring with CGM revealed that hypoglycemia persisted after bolus G-tube feeds. A gastric emptying study showed severely delayed gastric emptying (liquid half-emptying time of 370 minutes; upper limit of normal 45-60 minutes). Acarbose and cornstarch prior to bolus feeds were unsuccessful in preventing hypoglycemia. Erythromycin was trialed for gastroparesis but discontinued when it worsened hypoglycemia. Feeds were lengthened to continuous enteral feeds, which improved blood glucose values.
At 19 months old, he was switched to a gastrojejunostomy (GJ) tube due to multiple G-tube malfunctions and gastroparesis. CGM was used to guide feeding adjustments. Continuous G-tube feeds, with short breaks, were transitioned to J-tube feeds. After oral intake of 5 to 10 g of carbohydrates was introduced, CGM trends revealed dysglycemia classic for late dumping syndrome, with postprandial hyperglycemia (180-300 mg/dL) about 1 hour after oral intake followed by hypoglycemia (48-65 mg/dL) 3 hours later (Fig. 1B). Occasional hypoglycemia after oral intake is ongoing and is treated with a small volume of cherry syrup via G-tube.
Patient 3
A 13-month-old male with repaired esophageal atresia and distal tracheoesophageal fistula type C requiring esophageal dilations for strictures and G-tube placement for oral aversion presented with a hypoglycemic seizure. The serum BG was noted to be 17 mg/dL and occurred 2 hours after a bolus G-tube feed. He had previously been evaluated at 8 and 9 months of age for seizure-like activity. Video electroencephalography was unremarkable and the episodes were attributed to Sandifer syndrome, a manifestation of GERD characterized by abnormal and dystonic movements of the head, neck, and trunk [7]. During one admission, he had a serum BG of 52 mg/dL and follow-up POC BG of 89 mg/dL.
During this admission at 13 months of age, intermittent blood glucose monitoring did not capture his asymptomatic hypoglycemia episodes, so a CGM device was placed. Abdominal radiograph, upper GI series, gastric emptying scan, and glucose tolerance testing did not fulfill existing diagnostic criteria for either early or late dumping syndrome [1]. CGM profiles revealed hyperglycemia to BG 200 to 300 mg/dL at 1 hour after bolus feeds, followed by hypoglycemia 2 hours after feeds (Fig. 1C). CGM expedited the attainment of a critical sample, notable for hyperinsulinemic hypoglycemia to serum BG 15 mg/dL with a lack of counter-regulatory cortisol rise, and glucagon stimulation test with a robust glycemic response (Table 2). A subsequent cosyntropin stimulation test was normal (Table 2). A fasting study confirmed physiologic, ketotic hypoglycemia after 16.5 hours, and his postprandial, hyperinsulinemic hypoglycemia was attributed to late dumping syndrome. CGM showed normoglycemia on smaller daytime bolus enteral feeds and overnight continuous enteral feeds (Fig. 1D), and the child was discharged home with a glucometer and instructions to treat hypoglycemia with small volumes of juice.
He was subsequently readmitted for feeding adjustments, and CGM safely guided these changes. At 18 months of age, cornstarch was added to daytime intermittent bolus feeds. After several months, his mother discontinued cornstarch due to normal POC BGs at home. At 29 months of age, CGM again revealed postprandial hyperglycemia to BG 200 to 300 mg/dL followed by asymptomatic hypoglycemia to BG 35 mg/dL at 1.5 to 2 hours after feeds, which would have likely been missed with intermittent home POC BG monitoring. He was able to maintain normoglycemia with oral feeds, and his enteral feeds were discontinued. At 32 months of age, his G-tube was removed, and he experienced no further hypoglycemic episodes or seizure-like activity.
Discussion
Postprandial hypoglycemia due to late dumping syndrome can occur after Nissen fundoplication and other gastric surgeries, but it is difficult to detect in young children. Previous authors have encouraged a low threshold for glucose monitoring if a child has feeding difficulties after gastric procedures, citing the wide variability in clinical presentations of dumping syndrome in children [8, 9]. After initiating an asymptomatic hypoglycemia screening program, one institution noted that nearly a quarter of children who underwent fundoplication developed postprandial hypoglycemia within one week. Only half of these children exhibited other symptoms of dumping syndrome [10].
We have presented cases of 3 young children who required multiple hospitalizations to diagnose and manage postprandial hypoglycemia, which was ultimately attributed to late dumping syndrome. Prior to being diagnosed with dumping syndrome, one child presented with seizures, which were misattributed to Sandifer syndrome. The seizures were likely caused by undiagnosed hypoglycemia. In each case, there was evidence of asymptomatic hypoglycemia and blunted counter-regulatory hormonal responses, with low counter-regulatory cortisol but subsequently normal cosyntropin stimulation testing. These observations highlight the challenges in diagnosing late dumping syndrome in a younger pediatric population, particularly infants and toddlers, who have limited ability to communicate. Parents and health care providers may miss subtle signs of hypoglycemia, even with intermittent glucose monitoring. Further complicating this scenario is the rapid development of hypoglycemia unawareness, in which profound and recurrent hypoglycemia blunts neuroglycopenic symptoms and counter-regulatory responses [3, 11]. Thus, based on the prior experiences of other institutions, [8–10] and the cases described herein, we suspect that postprandial hypoglycemia due to late dumping syndrome is underdiagnosed, and is more prevalent than previously recognized. Even when diagnosed, we suspect that there are significant delays in diagnosis, as noted with our case series.
In approaching the diagnosis, one must consider the differences between early and late dumping syndrome. Closely monitoring for the timing or presence of vasomotor and gastrointestinal symptoms (early dumping syndrome) or reactive hypoglycemia (late dumping syndrome) in the hours following a glucose load can aid diagnosis [12]. Adult consensus guidelines define an increase in hematocrit >3% or a rise in heart rate >10 beats per minute by 30 minutes after the start of a modified oral glucose tolerance test as diagnostic of early dumping syndrome. The development of a blood glucose level <50 mg/dL, about 1 to 3 hours after the glucose load, is diagnostic of late dumping syndrome [13]. In our cases, none of the patients displayed signs or symptoms of gastrointestinal upset or vasomotor symptoms that would be characteristic of early dumping syndrome. This highlights the importance of understanding that early and late dumping syndrome can occur in isolation of one another.
Furthermore, as pathophysiology of late dumping syndrome is hormonal, imaging modalities may not detect the diagnosis [12]. Reactive hypoglycemia is triggered by accelerated delivery of a carbohydrate load into the small intestine, with resultant hormonal dysregulation, including hyperglycemia and a hyperinsulinemic response followed by a precipitous fall in serum glucose [2]. In all of our cases, gastric imaging studies, including gastric emptying studies, upper GI studies, and nuclear medicine studies, had low diagnostic yield. The imaging studies were either normal or displayed results contrary to what would be expected in dumping syndrome. Thus, the pursuit of multiple imaging studies led to a delay in diagnosis, extension of hospitalization, and heightened family frustration.
Given the dynamic nature of glycemic changes postprandially during dumping syndrome, it is not surprising that intermittent use of glucometer testing failed to identify the pattern of glycemic excursions characteristic of dumping syndrome in our cases. CGM was essential for diagnosis of late dumping syndrome by revealing the dynamic glycemic excursion, with hyperglycemia following by hypoglycemia, after feeds (Fig. 1, A-C). Critical samples showing a hyperinsulinemic response after a glucose load, in 2 of the cases, corroborated this diagnosis (Table 2).
CGM was also useful to guide therapeutic interventions that included feeding manipulations, cornstarch, and acarbose. First-line treatment of postprandial hypoglycemia due to late dumping syndrome includes the use of dietary modification with more frequent or continuous feeds and dietary supplementation with fiber, cornstarch, or gelling agents. Second-line therapy is acarbose, an alpha glucosidase inhibitor that blunts carbohydrate breakdown. Somatostatin analogues are reserved for patients who do not respond to dietary adjustments and acarbose [14]. CGM enabled safe modification of the feeding and medication regimens of the 3 patients described herein (Fig. 1D). CGM also enabled families to identify and intervene on hypoglycemic episodes that may have gone unnoticed with traditional POC glucometer use. In the event of hypoglycemia, families were instructed to give a small quantity of rapid-acting glucose. Early hypoglycemia intervention is particularly important in young children as recurrent hypoglycemia is associated with poor long-term neurocognitive outcomes [15].Thus, our cases contribute to a growing body of evidence that supports the use of CGM to diagnose and manage reactive hypoglycemia [16-19].
We conclude that because of the variable results in imaging studies and the rapid development of hypoglycemia unawareness in children, CGM should be the first line in evaluating children that may have hypoglycemia after gastric procedures. Abnormal blood glucoses may be missed with intermittent glucometer checks, and postprandial hypoglycemia in children with a history of gastric surgery is likely underdiagnosed. Clinicians should maintain a high index of suspicion for dumping syndrome when evaluating children with a history of gastric surgeries, even if the child exhibits no or few clinical symptoms. CGM can help with earlier diagnosis of dumping syndrome and can reveal the characteristic pattern of glycemic dysregulation. Furthermore, it can be used to efficiently evaluate the effectiveness of various treatments and feeding regimens.
Acknowledgments
Financial support: Research reported in this publication was supported by the National Institute of Diabetes and Digestive and Kidney Diseases (award number T32DK007161 awarded to HC, AH, and JYL) and the Eunice Kennedy Shriver National Institute of Child Health & Human Development (award number F32HD098763 awarded to JYL) of the National Institutes of Health. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.
Abbreviations
BG blood glucose
CGM continuous glucose monitoring
GERD gastroesophageal reflux disease
GI gastrointestinal
GLP-1 glucagon-like peptide-1
G-tube gastrostomy tube
POC point-of-care
Additional Information
Disclosures: H.C., F.A., A.H., J.Y.L., and S.E.G. have no relevant financial interests to disclose.
Data Availability
Data sharing is not applicable to this article as no datasets were generated or analyzed during the current study. | Recovering | ReactionOutcome | CC BY-NC-ND | 33506160 | 20,257,580 | 2021-03-01 |
Give an alphabetized list of all active substances of drugs taken by the patient who experienced 'Accidental overdose'. | Biomarker-guided tuberculosis preventive therapy (CORTIS): a randomised controlled trial.
Targeted preventive therapy for individuals at highest risk of incident tuberculosis might impact the epidemic by interrupting transmission. We tested performance of a transcriptomic signature of tuberculosis (RISK11) and efficacy of signature-guided preventive therapy in parallel, using a hybrid three-group study design.
Adult volunteers aged 18-59 years were recruited at five geographically distinct communities in South Africa. Whole blood was sampled for RISK11 by quantitative RT-PCR assay from eligible volunteers without HIV, recent previous tuberculosis (ie, <3 years before screening), or comorbidities at screening. RISK11-positive participants were block randomised (1:2; block size 15) to once-weekly, directly-observed, open-label isoniazid and rifapentine for 12 weeks (ie, RISK11 positive and 3HP positive), or no treatment (ie, RISK11 positive and 3HP negative). A subset of eligible RISK11-negative volunteers were randomly assigned to no treatment (ie, RISK11 negative and 3HP negative). Diagnostic discrimination of prevalent tuberculosis was tested in all participants at baseline. Thereafter, prognostic discrimination of incident tuberculosis was tested in the untreated RISK11-positive versus RISK11-negative groups, and treatment efficacy in the 3HP-treated versus untreated RISK11-positive groups, during active surveillance through 15 months. The primary endpoint was microbiologically confirmed pulmonary tuberculosis. The primary outcome measures were risk ratio [RR] for tuberculosis of RISK11-positive to RISK11-negative participants, and treatment efficacy. This trial is registered with ClinicalTrials.gov, NCT02735590.
20 207 volunteers were screened, and 2923 participants were enrolled, including RISK11-positive participants randomly assigned to 3HP (n=375) or no 3HP (n=764), and 1784 RISK11-negative participants. Cumulative probability of prevalent or incident tuberculosis disease was 0·066 (95% CI 0·049 to 0·084) in RISK11-positive (3HP negative) participants and 0·018 (0·011 to 0·025) in RISK11-negative participants (RR 3·69, 95% CI 2·25-6·05) over 15 months. Tuberculosis prevalence was 47 (4·1%) of 1139 versus 14 (0·78%) of 1984 in RISK11-positive compared with RISK11-negative participants, respectively (diagnostic RR 5·13, 95% CI 2·93 to 9·43). Tuberculosis incidence over 15 months was 2·09 (95% CI 0·97 to 3·19) vs 0·80 (0·30 to 1·30) per 100 person years in RISK11-positive (3HP-negative) participants compared with RISK11-negative participants (cumulative incidence ratio 2·6, 95% CI 1·2 to 5·9). Serious adverse events related to 3HP included one hospitalisation for seizures (unintentional isoniazid overdose) and one death of unknown cause (possibly temporally related). Tuberculosis incidence over 15 months was 1·94 (95% CI 0·35 to 3·50) versus 2·09 (95% CI 0·97 to 3·19) per 100 person-years in 3HP-treated RISK11-positive participants compared with untreated RISK11-positive participants (efficacy 7·0%, 95% CI -145 to 65).
The RISK11 signature discriminated between individuals with prevalent tuberculosis, or progression to incident tuberculosis, and individuals who remained healthy, but provision of 3HP to signature-positive individuals after exclusion of baseline disease did not reduce progression to tuberculosis over 15 months.
Bill and Melinda Gates Foundation, South African Medical Research Council.
Introduction
Large-scale prevention of progression from Mycobacterium tuberculosis infection to tuberculosis disease is key to achieving WHO End TB Strategy targets, yet tuberculin skin tests (TST) and interferon (IFN) γ release assays have poor specificity for incident tuberculosis.1 A biomarker-targeted prevention strategy using a highly specific correlate of risk (COR) for incident tuberculosis, in tandem with effective short-course tuberculosis preventive therapy (TPT),2 might impact the epidemic by preventing incident tuberculosis disease before transmission.3 Modelling suggests a three-times reduction in burden of TPT if targeted by COR, compared with IFNγ release assays and TST.4 Furthermore, because active tuberculosis disease should be excluded before starting TPT, additional utility of the prognostic COR as a screening (triage) test to identify undiagnosed tuberculosis disease would allow earlier curative treatment. WHO and FIND have developed target product profiles (TPP) for triage tests for tuberculosis (optimal and minimum sensitivity of >95% and >90%, and specificity of >80% and >70%, respectively),5 and incipient tuberculosis tests (minimum sensitivity and specificity of 75% and 75%, and optimal sensitivity and specificity of 90% and 90%, respectively).6
Research in context
Evidence before this study
Host blood RNA signatures have potential as tuberculosis triage or diagnostic tests, and as predictive tests to target tuberculosis preventive therapy. We searched MEDLINE, Scopus, Web of Science, and EBSCO libraries for publications between Jan 1, 2005, and May 31, 2020, using the search terms “Tuberculosis” OR “TB” OR “Mycobacterium tuberculosis” OR “MTB” AND “diagnosis” OR “diagnostic” OR “detect” OR “predic”OR “prognosis” OR “prognostic” OR “screen” AND “Blood Biomarker” OR “blood biomarkers” OR “bio-signature” OR “gene expression” OR “genetic transcription” OR “host blood” OR “immune marker” OR “immunologic marker” OR “Ribonucleic Acid” OR “RNA” OR “signature” OR “surrogate endpoint” OR “surrogate marker” OR “transcriptome” OR “transcriptomic” AND “Area under curve” OR “AUC” OR “receiver operating characteristic” OR “ROC” OR “Accuracy” OR “Performance” OR “sensitivity” OR “specificity”. Studies comparing blood RNA signatures in individuals with tuberculosis versus Mycobacterium tuberculosis-uninfected controls, individuals with other respiratory diseases, or with M tuberculosis infection and using a microbiological reference standard of either sputum M tuberculosis culture, Xpert MTB/RIF, or smear microscopy for tuberculosis diagnosis, were included.
28 studies reported evaluation of 32 host blood RNA signatures for diagnosis or prediction of progression to tuberculosis disease in 83 cohorts. Only two studies prospectively tested performance of an RNA signature in all evaluable participants; the remainder used a case-control design. Multiple studies have tested tuberculosis preventive therapy in people with M tuberculosis latent tuberculosis infection. No studies have tested efficacy of tuberculosis preventive therapy to avert disease in RNA signature-positive people.
Added value of this study
This large randomised, controlled trial in five South African communities prospectively tested diagnostic and prognostic performance of an RNA signature (RISK11) in all evaluable participants, and estimated efficacy of tuberculosis preventive therapy to avert disease in RNA signature-positive people. More than 1% of HIV-uninfected community volunteers had previously undiagnosed, microbiologically confirmed tuberculosis at screening, more than 80% of which was asymptomatic. RISK11 showed moderate performance for tuberculosis triage, but good performance for diagnosis of symptomatic tuberculosis, and for short-term prediction of incident tuberculosis. 3 months of once-weekly, high-dose isoniazid and rifapentine (3HP) did not reduce incident disease in RISK11-positive individuals over 15 months of follow-up.
Implications of all the available evidence
Host blood biomarker development must consider that subclinical tuberculosis might be characterised by more heterogenous, or less pronounced blood inflammatory responses than symptomatic tuberculosis, or both, which will affect RNA signature performance. RISK11 might be better suited to screening of symptomatic individuals with possible tuberculosis than for mass community-based screening. RISK11 can identify those at highest risk for short-term progression to disease, but a more potent regimen than 3HP might be needed to prevent tuberculosis in RISK11-positive individuals.
We previously developed a 16-gene transcriptomic signature by whole blood RNA sequencing for identification of individuals at high risk of developing tuberculosis (the Zak16 signature).7, 8 Measurement of Zak16 was adapted to quantitative RT-PCR (RT-qPCR), and predictive ability for incident tuberculosis was validated in an independent longitudinal cohort of household contacts of tuberculosis patients.8 We reduced this signature to 11 genes (RISK11) with equivalent performance,9, 10 to allow testing in 96-well PCR format. Zak16 and RISK11 also did well as non-sputum screening tests for prevalent, active tuberculosis in case-control studies, measured by RNA sequencing, microarray,7, 8 or microfluidic RT-qPCR.9, 10 In a 2020 systematic review and patient-level pooled meta-analysis of 17 transcriptomic signatures for prognosis of incident tuberculosis, Zak16 was among eight signatures that achieved a positive predictive value above the WHO TPP benchmark for incipient tuberculosis tests.11 Since case-control studies might overestimate performance characteristics, testing in unselected populations is needed.
We report on a randomised controlled trial (CORTIS; NCT02735590), which prospectively measured diagnostic and prognostic performance of RISK11 for triage of prevalent and prediction of incident tuberculosis in South African adults; and, in parallel, estimated efficacy of short-course TPT to avert incident disease in RISK11-positive individuals.
Methods
Study design
This randomised controlled trial used a hybrid treatment selection, three-group study design to evaluate efficacy of the intervention and, in parallel, performance of the biomarker used to allocate that intervention (figure 1).2 The coprimary aims were to test, over 15 months, whether RISK11 status differentiates between people with and without cumulative prevalent or incident tuberculosis; and whether preventive therapy (weekly high-dose isoniazid and rifapentine for 12 weeks [3HP]) reduces tuberculosis incidence among RISK11-positive people compared with active surveillance only. RISK11 performance to detect prevalent tuberculosis was evaluated in all groups at baseline. RISK11 performance to predict incident tuberculosis was evaluated in the untreated RISK11-positive and RISK11-negative groups, and treatment efficacy was estimated from the 3HP treated and untreated RISK11-positive groups, after omitting participants with baseline tuberculosis. Efficiency of the hybrid study design was maximised by using the RISK11-positive and 3HP-negative group to evaluate both biomarker performance and treatment efficacy.Figure 1 Study design
The prevalence of RISK11 positivity was not precisely known in the study population; therefore, the number of individuals to be screened and the randomisation of RISK11-negative participants to enrolment was monitored and adjusted adaptively to ensure concurrent enrolment of the target number of RISK11-positive and RISK11-negative participants, per protocol specifications. The study used a three-group design to evaluate efficacy of the intervention and, in parallel, performance of the biomarker used to allocate that intervention. Diagnostic performance for differentiation of prevalent tuberculosis was tested in all three groups at baseline; prognostic performance for differentiation of incident tuberculosis over 15 months was tested in the two untreated groups (untreated RISK11 positive and untreated RISK11 negative); and treatment efficacy of 3HP over 15 months was tested in the two RISK11-positive groups (treated and untreated RISK11 positive). *Participants evaluated for eligibility at screening and enrolment. †Groups randomly assigned in blocks to ensure concurrent enrolment.
Routine implementation of TPT requires that patients are screened to exclude prevalent tuberculosis before TPT is provided to prevent incident disease. Therefore, because risk for prevalent and incident tuberculosis by RISK11 status must be understood before efficacy of preventive therapy against incident tuberculosis in RISK11-positive people can be interpreted, these secondary analyses are presented before the primary analysis of treatment efficacy.
The trial protocol (appendix p 21) was approved by the South African Health Products Regulatory Agency (20160305) by the Institutional Human Ethics Committees of participating sites; and was registered on ClinicalTrials.gov (NCT02735590). All participants provided written informed consent in their language of choice.
Participants
Adult volunteers living in tuberculosis-endemic communities in South Africa were recruited at five sites (South African Tuberculosis Vaccine Initiative, Worcester; Immunology Research Group, Stellenbosch University, Ravensmead; Aurum Institute, Klerksdorp and Rustenberg; and Centre for the AIDS Programme of Research in South Africa, Durban). Community-based recruitment was by word-of-mouth, house-to-house visits, and liaison with non-governmental organisations. Recruitment did not target groups at high risk of tuberculosis, such as household contacts. Eligible participants were aged between 18 years and 59 years, HIV-negative, without a history of tuberculosis disease in the last 3 years or preselected comorbidities (appendix p 8).
Screening
Venous blood was collected in PAXgene RNA tubes from all potentially eligible people at screening, frozen at −20°C, and shipped weekly to the South African Tuberculosis Vaccine Initiative Immunology Laboratory for RISK11 testing by qRT-PCR assay. Participants with a RISK11 score of at least 60% were classified a priori as RISK11 positive and less than 60% as RISK11 negative. This 60% threshold was the optimal point at which sensitivity and specificity for prognosis of incident tuberculosis were balanced in case-control studies.2 Samples with failed reference primer-probe reactions, with marked deviation in internal positive control sample from historical runs, or more than 30% failed interferon-stimulated genes primer-probe reactions (see quality control criteria and analysis script in Bitbucket instance) were classified as indeterminate. Per-participant qualitative results (RISK11 positive and RISK11 negative) were provided to the Triclinium Clinical Development (TCD) Data Centre for participant randomisation (see appendix pp 2–3).
Randomisation and masking
Assignment to study group was managed by an unmasked randomisation team from the TCD Data Centre, based on RISK11 status. RISK11-positive volunteers were randomly assigned (1:2; block size 15) to either open-label 3HP (3HP-positive group), or active tuberculosis surveillance without 3HP (3HP-negative group), in accordance with a randomisation schedule generated using SAS, version 9.4. RISK11-negative volunteers were concurrently randomly assigned either to active tuberculosis surveillance (3HP-negative group) or to non-participation, to enrich the study population for RISK11-positive participants.
Study group allocation was revealed to site staff after enrolment of eligible participants within 28 days of screening. The 3HP-negative group was double-blinded to RISK11 status, but unblinded to treatment allocation; the 3HP-positive group was unblinded to both RISK11-positive status and treatment allocation (figure 1). RISK11-positive participants randomly assigned to active surveillance did not receive a placebo, to maintain blinding of participants and study team members to RISK11 status.
Procedures
Target enrolment was maximally 3200 participants (1500 RISK11 positive and 1700 RISK11 negative). The randomisation ratio for RISK11-negative volunteers was adapted to ensure concurrent enrolment of the recruitment target. Adaptations occurred at intervals, informed by 3-monthly operational monitoring reports based on enrolment rate, RISK11-positive and RISK11-negative prevalence, and tuberculosis case accrual blinded to RISK11 status (appendix p 7).
Enrolment procedures included phlebotomy for IFNγ release assays (QuantiFERON TB Gold-Plus, Qiagen), tuberculosis symptom screen (a positive tuberculosis symptom screen included one or more symptoms of persistent unexplained cough, fever, night sweats, weight loss, or any haemoptysis), and collection of two spontaneous expectorated sputum samples for Xpert MTB/RIF assay (Cepheid) from all sputum-productive participants, regardless of symptoms.
All participants attended up to seven study visits, including four study site visits at months 3, 6, 12, and 15 (end of study), and three telephonic contact or field visits at months 1, 2, and 9. HIV testing was repeated at months 6 and 12.
Participants in the 3HP group received open-label, high-dose isoniazid (15 mg/kg; maximum dose 900 mg) with pyridoxine supplementation (25 mg) and rifapentine based on body weight (>32–50 kg, 750 mg; >50 kg, 900 mg), given weekly as directly observed oral doses, ideally with food, over 12 weeks. Completion of 3HP treatment was defined as receipt of 11 doses within 16 weeks (appendix p 3).
Outcomes
The two primary outcome measures were RISK11-positive to RISK11-negative risk ratio (RR) for prevalent or incident tuberculosis disease, and 3HP treatment efficacy through 15 months. Diagnostic performance for prevalent tuberculosis was evaluated on the presence of tuberculosis at the enrolment visit within the ITT cohort.
Participants in the 3HP group had each dose directly observed by study staff, and attended clinic for evaluation of solicited adverse events and possible adverse events of special interest at weeks 1–11. Solicited adverse events included gastrointestinal signs and symptoms suggestive of hepatotoxicity, such as nausea, vomiting, and jaundice. Possible hypersensitivity reactions, including influenza-like illness, were reported as adverse events of special interest. Safety events meeting the definition for a serious adverse event, whether deemed related or unrelated to study drug, were reported for both all participants through end of study.
Statistical analysis
The intention-to-treat (ITT) cohort included all enrolled participants who completed investigation for tuberculosis endpoints at baseline. The modified intention-to-treat (mITT) cohort included all participants in the ITT population who completed at least one post-baseline tuberculosis endpoint investigation and omitted participants with endpoint-defined tuberculosis disease at baseline (prevalent tuberculosis).
The diagnostic RR was estimated as a proportion of participants with tuberculosis disease among RISK11-positive divided by RISK11-negative participants. Prognostic performance for incident tuberculosis after enrolment was evaluated among 3HP-negative participants within the mITT cohort (ie, excluding participants with tuberculosis at baseline). Prognostic RR was estimated as the cumulative incidence through 15 months for RISK11-positive divided by RISK11-negative participants. The primary RR was an estimate of the probability of having prevalent tuberculosis or developing incident tuberculosis among RISK11-positive divided by RISK11-negative participants; this combined probability of prevalent and incident tuberculosis was computed for each group as the probability of prevalent tuberculosis plus the probability of incident tuberculosis through 15 months (conditioned on not having prevalent tuberculosis). Efficacy of 3HP preventive therapy to reduce the rate of incident tuberculosis disease compared with the untreated RISK11-positive participants was also evaluated in the mITT population. Treatment efficacy was estimated as one minus the cumulative incidence of RISK11-positive and 3HP-positive participants divided by RISK11-positive and 3HP-negative participants through 15 months. A per-protocol analysis of treatment efficacy was done and excluded RISK11-positive and 3HP-positive participants that received less than 11 of the 12 weekly doses of 3HP.
For statistical efficiency, a random subset of RISK11-negative participants were enrolled, therefore creating an ITT cohort artificially enriched with RISK11-positive participants. Therefore, unless stated otherwise, all analyses were adjusted so that results reflected the screened population. Secondary performance metrics such as sensitivity and specificity were estimated using standard formulas with binary endpoints; a percentile bootstrap with 20 000 samples was used to estimate 95% CIs. For descriptive analyses (Table 1, Table 2), rank-based Wilcoxon rank-sum tests were used to compare continuous variables in RISK11-positive versus RISK11-negative groups. Fisher's exact test was used to compare binary readouts; p values in Table 1, Table 2 were not adjusted for multiple comparisons. The prespecified statistical analysis plan is included in the appendix (p 82) and contains detailed description of the statistical methods.Table 1 Baseline characteristics and primary tuberculosis endpoints by group
Total (n=2923) RISK11 positive and 3HP positive (n=375) RISK11 positive and 3HP negative (n=764) RISK11 negative (n=1784) RISK11 positive vs RISK11 negative, p value*
Sex
Female 1585 (54·2%) 213 (56·8%) 469 (61·4%) 903 (50·6%) <0·001
Male 1338 (45·8%) 162 (43·2%) 295 (38·6%) 881 (49·4%) ..
Age, years 28·5 (9·0) 28·8 (9·5) 28·4 (9·2) 28·4 (8·7) 0·541
Race or ethnicity
Asian 4 (0·1%) 0 1 (0·1%) 3 (0·2%) 0·567
Black African 1947 (66·6%) 227 (60·5%) 477 (62·4%) 1243 (69·7%) <0·001
White 4 (0·1%) 0 1 (0·1%) 3 (0·2%) 0·567
Mixed race 968 (33·1%) 148 (39·5%) 285 (37·3%) 535 (30·0%) <0·001
Body-mass index, kg/m2 24·6 (7·7) 24·1 (6·3) 24·4 (6·1) 24·9 (8·6) 0·354
Previous tuberculosis 230 (7·9%) 36 (9·6%) 75 (9·8%) 119 (6·7%) 0·003
Smoking 1478 (50·6%) 203 (54·1%) 391 (51·2%) 884 (49·6%) 0·170
Family tuberculosis history 462 (15·8%) 66 (17·6%) 110 (14·4%) 286 (16·0%) 0·675
Interferon γ release assay positive 1895 (64·8%) 250 (66·7%) 528 (69·1%) 1117 (62·6%) <0·001
Follow-up, months 15 (9·4–15·0) 15 (11·1–15·0) 15 (9·1–15·0) 13·6 (9·4–15·0) 0·056
Prevalent tuberculosis, n (probability, 95% CI) 61 (1·1%, 0·77–1·6)† 47 (4·1%, 3·1–5·4)‡ 47 (4·1%, 3·1–5·4)§ 14 (0·78%, 0·47–1·3) NA
Incident tuberculosis, n (cases per 100 person years, 95% CI) 24 (1·05, 0·59–1·5)§ 6 (1·9, 0·35–3·5) 14 (2·09, 0·97–3·19) 10 (0·80, 0·30–1·30) NA
Cumulative tuberculosis, n (probability, 95% CI)¶ 85 (0·022, 0·016–0·028)† 61 (0·066, 0·049–0·084)‖** 61 (0·066, 0·049–0·084)** 24 (0·018, 0·011–0·026) NA
Data are n (%), mean (SD), or median (IQR), unless stated otherwise. Secondary tuberculosis endpoints by group are in the appendix (p 13). NA=not applicable.
* For continuous data, p values from Wilcoxon rank sum test. For categorical data, p values from Fischer's exact test.
† Overall rate estimates are weighted combinations of the enrolled participants to reflect the screened population.
‡ Overall incidence and cumulative tuberculosis excludes RISK11-positive and 3HP-positive incident cases.
§ Prevalent tuberculosis among RISK11 positive was assessed by combining the 3HP-negative and 3HP-positive groups. Value is repeated for RISK11 positive and 3HP positive, and RISK11 positive and 3HP negative.
¶ Probability of observing prevalent or incident tuberculosis over 15 months.
‖ Probability of prevalent or incident tuberculosis not estimated for RISK11-positive and 3HP-positive because it would combine data from before and after 3HP treatment and is therefore potentially misleading.
** Estimate for RISK11 positive includes 3HP-positive prevalent cases and 3HP-negative prevalent and incident cases. Value is repeated for RISK11 positive and 3HP positive, and RISK11 positive and 3HP negative.
Table 2 Performance of RISK11 and IGRA for prevalent and incident tuberculosis
Prevalent tuberculosis (ITT cohort) Incident tuberculosis (mITT cohort)*
RISK11 (60)† RISK11 (26)† IGRA RISK11 (60)† RISK11 (26)† IGRA
Risk ratio 5·13 (2·93 to 9·43) 7·39 (3·46 to 25·69) 4·43 (1·93 to 14·18) 2·61 (1·15 to 5·94) 2·67 (1·04 to 8·66) 2·83 (0·95 to 99·79)
Biomarker prevalence 9·2% (9·2 to 9·2) 25·8% (24·1 to 27·4) 63·4% (61·3 to 65·4) 9·0% (9·0 to 9·0) 25·3% (23·7 to 26·9) 63·2% (61·1 to 65·3)
AUC‡ 0·77 (0·68 to 0·86) .. 0·66 (0·58 to 0·73) 0·63 (0·47 to 0·80) .. 0·67 (0·54 to 0·79)
Sensitivity 34·9% (23·7 to 52·2) 72·1% (54·5 to 90·2) 88·7% (77·1 to 96·4) 25·0% (12·7 to 45·9) 47·5% (25·9 to 75·0) 83·2% (61·9 to 100·0)
Specificity 91·0% (90·9 to 91·1) 74·7% (73·1 to 76·4) 36·9% (34·9 to 39·0) 91·1% (91·0 to 91·2) 74·9% (73·2 to 76·5) 37·0% (34·9 to 39·1)
PPV§ 4·1% (3·0 to 5·4) 3·1% (2·0 to 4·3) 1·5% (1·0 to 2·2) 1·9% (0·9 to 3·0) 1·3% (0·6 to 2·1) 0·9% (0·5 to 1·4)
PPV (2% incidence)¶ .. .. .. 6·7% (3·5 to 11·8) 4·6% (2·5 to 7·1) 3·3% (2·5 to 3·9)
NPV§ 99·2% (98·8 to 99·6) 99·6% (99·2 to 99·9) 99·7% (99·3 to 99·9) 99·4% (99·0 to 99·8) 99·5% (99·1 to 99·9) 99·7% (99·2 to 100·0)
NPV (2% incidence)¶ .. .. .. 97·9% (97·6 to 98·5) 98·2% (97·5 to 99·2) 98·8% (97·4 to 100·0)
NNS or NNT‖ 29·9 (21·8 to 46·6) 37·8 (25·5 to 65·7) 83·1 (53·2 to 179·8) 75·1 (40·4 to 277·5) 123·8 (47·2 to 834·1) 168 (−440 to 1059)
Data are risk ratio (95 %CI), % (95% CI), AUC (95% CI), or NNS or NNT (95% CI). ITT=intention to treat. mITT=modified intention-to-treat. IGRA=interferon γ release assay. AUC=area under the receiver operating characteristic curve. PPV=positive predictive value. NPV=negative predictive value. NNS=number needed to screen. NNT=number needed to treat.
* Computed over 15-month prognostic window. Performance of RISK11 and IGRA for incident tuberculosis over 6-month and 12-month prognostic windows is in the appendix (p 16).
† RISK11 score threshold at 60% or 26%.
‡ AUC is computed across all score thresholds and value is presented under RISK11 (60).
§ Computed using the prevalence and incidence rates in the trial population as appropriate.
¶ Computed assuming 2% annual incidence of tuberculosis in the population.
‖ NNS for prevalent tuberculosis; NNT for incident tuberculosis. Performance of RISK11 and IGRA for prevalent and incident tuberculosis based on secondary endpoint (≥1 sample+) is in the appendix (p 15).
The study was designed to have 90% power to reject the null hypothesis of a RISK11-positive and RISK11-negative cumulative risk ratio less than 2 with one-sided alpha of 0·025. For treatment efficacy there was 80% power to reject the null hypothesis of efficacy less than 20%, with one-sided alpha of 0·05 and under the alternative design hypothesis that efficacy was 80%. To compute statistical power for these aims, a stochastic simulation of the trial was constructed, based on which we expected to observe 33 tuberculosis disease endpoints among 1500 RISK11-positive participants and seven tuberculosis disease endpoints among 1700 RISK11-negative participants (appendix p 6).
Role of the funding source
The trial was funded by the Bill & Melinda Gates Foundation (OPP1116632, OPP1137034) and the Strategic Health Innovation Partnerships Unit of the South African Medical Research Council, with funds received from the South African Department of Science and Technology. The Gates Foundation contributed to the study design. The regulatory sponsor was the University of Cape Town. Rifapentine (PRIFTIN) was donated by the manufacturer (Sanofi), who had no role in the design, implementation, analysis, or reporting of the trial. All authors had access to all the data reported in the study. The corresponding author had final responsibility for the decision to submit for publication.
Results
Between Sept 20, 2016, and Oct 19, 2018, 20 207 volunteers consented to participation; 16 248 met inclusion criteria at screening and 15 777 with a RISK11 result were potentially eligible for enrolment (figure 2). Of the 20 207 adults assessed for eligibility, common reasons for exclusion included HIV infection (1246 [6·1%]) and comorbid conditions (1369 [6·8%]; appendix p 8). 2923 eligible participants were enrolled after randomisation (1784 [61·0%] RISK11 negative and 1139 [39·0%] RISK11 positive; table 1).Figure 2 Trial profile
ITT=intention to treat. mITT=modified intention to treat. LTFU=lost to follow-up. PP=per protocol analysis. *585 participants did not complete the trial for reasons including: 53 (9%) pregnancies, 22 (4%) investigator withdrawals, 46 (8%) consent withdrawals, 26 (4%) HIV infections, 422 (72%) LTFU, and 16 (3%) deaths.
Participants were enrolled at five geographically diverse sites across South Africa (appendix pp 9–11). Among participants with a RISK11 result, 1434 (9·3%) of 15 494 were RISK11 positive, with the proportion ranging from 6·2% to 13·0% across the five sites. RISK11-positive participants were randomly asigned either to receive treatment (375 [32·9%] RISK11 positive and 3HP positive) or undergo observation without treatment (764 [67·1%] RISK11 positive and 3HP negative).
There were no significant differences in smoking history, family history of tuberculosis, or febrile illness between RISK11-positive and RISK11-negative participants (table 1). A higher proportion of RISK11-positive (75 [9·8%] of 364) than RISK11-negative (119 [6·7%] of 1784) participants reported previous tuberculosis disease (p=0·003). Compared with RISK11 negative participants, a greater proportion of RISK11-positive participants were female and mixed race (p<0·001; table 1).
Median duration of follow-up for incident tuberculosis was 13·9 months (IQR 9·0–15·0) and 1879 (66%) of 2500 3HP-negative mITT participants attended at least six scheduled visits. 1416 (49%) of 2838 participants were followed up for 15 months and 2160 (75%) of 2838 participants were followed up for at least 9 months. 585 (21%) of 2838 participants did not complete the study because of withdrawal, death, or loss to follow-up (figure 2; table 1).
Among 91 participants with tuberculosis who reached the primary endpoint, 61 were diagnosed with prevalent tuberculosis at baseline (47 RISK11 positive and 14 RISK11 negative; table 1; appendix p 13). Prevalence of tuberculosis in RISK11-positive and RISK11-negative participants was 4·1% (95% CI 3·1–5·4) and 0·78% (0·5–1·3), respectively (figure 3). Thereafter, 24 participants in the untreated group were diagnosed with incident tuberculosis disease (14 RISK11 positive and ten RISK11 negative; table 1; appendix p 13) with overall incidence of 1·05 cases (95% CI 0·59–1·5) per 100 person-years.Figure 3 RISK11 detection of combined prevalent and incident tuberculosis and diagnostic performance
(A) Prevalence of tuberculosis in RISK11-positive (47 cases,) and RISK11-negative (14 cases, red bar) participants at trial enrolment. Error bars depict 95% CI. Cumulative incidence probability of tuberculosis in RISK11-positive (14 cases, blue line) or RISK11-negative (10 cases, red line) mITT participants during follow-up. Shaded areas represent 95% CI. (B) Ratio of RISK11-positive versus RISK11 negative cumulative incidence probability of observing prevalent or incident tuberculosis disease, in the ITT population of the observation group. (C) RISK11 signature scores (each dot represents a participant) measured at screening in trial participants, stratified on tuberculosis diagnosis. Boxes depict IQR, midline represents the median, and whiskers indicate range among enrolled participants. (D) RISK11 signature scores measured at screening in prevalent tuberculosis cases with or without any tuberculosis symptoms, in incident tuberculosis cases or those who did not have a tuberculosis diagnosis. The enrolled population, not the screened population, is represented in (C) and (D), because a large fraction of RISK11-negative participants were not enrolled by design. (E) ROC curves depicting RISK11 diagnostic performance for prevalent tuberculosis in the ITT population, for prevalent tuberculosis among individuals with no symptoms of tuberculosis (asymptomatic) and among individuals with at least one symptom consistent with tuberculosis disease (symptomatic). Shaded areas represent the 95% CI. The grey and black dots indicate the minimum and optimal criteria, respectively, set out in the WHO target product profile for a triage test. The empty dot indicates the criteria set out in the WHO target product profile for a confirmatory diagnostic test. TRP=true positive rate. ITT=intention to treat. FPR=false positive rate. AUC=area under the receiver operating characteristic curve.
In the primary analysis of biomarker performance for cumulative tuberculosis, cumulative probability of observing prevalent or incident tuberculosis disease in the ITT population was 0·066 (95% CI 0·049–0·084) in RISK11-positive participants and 0·018 (0·011–0·025) in RISK11-negative participants, with a risk ratio of 3·69 (95% CI 2·25–6·05) over 15 months (figure 3).
A wide range of RISK11 scores was observed, irrespective of tuberculosis outcome (figure 3). Among enrolled participants, those who remained tuberculosis free (controls) had significantly lower RISK11 scores (24·2%, IQR 8·2–75·3) than those with prevalent or incident tuberculosis disease (76·7%, 36·6–94·4; Wilcoxon rank-sum test p<0·0001; figure 3).
In the secondary analysis of biomarker performance for prevalent tuberculosis, using the prespecified RISK11 test threshold (60%) there was 5·13-times (95% CI 3·01–10·69) increased risk of prevalent tuberculosis disease at baseline in RISK11-positive versus RISK11-negative participants, with sensitivity of 35% (95% CI 24–52) and specificity of 91% (95% CI 91–91; table 2). The receiver operating characteristic (ROC) analysis (figure 3) showed that a RISK11 threshold of 26% provided sensitivity of 72% (95% CI 54–90) and specificity of 75% (95% CI 73–76; table 2); with area under the diagnostic ROC curve (AUC) of 0·77 (95% CI 0·68–0·86). These performance estimates did not meet the minimum criteria for a tuberculosis triage test (table 2). 50 (83·6%) of 61 participants with prevalent tuberculosis had no symptoms compatible with tuberculosis disease, and the remaining 11 participants with at least one symptom consistent with tuberculosis had RISK11 scores of more than 80% (median 96%; figure 3; appendix p 14). Discrimination between symptomatic prevalent tuberculosis and symptomatic controls was high (AUC 0·97, 95% CI 0·95–0·99; figure 3) and, with a highly specific threshold, performance exceeded the optimal TPP for a tuberculosis triage test in this population. By contrast, RISK11 discriminated between asymptomatic controls and asymptomatic prevalent tuberculosis cases with an AUC of 0·75 (95% CI 0·66–0·84; figure 3).
In the secondary analysis of biomarker performance for incident tuberculosis, annualised incidence was 2·1 versus 0·8 per 100 person-years among the RISK11-positive versus RISK11-negative participants, respectively, which was equivalent to a 0·026 (95% CI 0·01–0·04) versus 0·010 (0·004–0·02) cumulative incident probability of developing tuberculosis disease over 15 months, respectively (figure 3). No incident tuberculosis cases were detected in RISK11-negative participants until 8·7 months (figure 3). Tuberculosis incidence through 15 months among RISK11-positive participants was 2·61 (95% CI 1·15–5·94) times higher than RISK11-negative participants (table 2); and the RISK11 signature discriminated between incident tuberculosis cases and controls with AUC of 0·63 (95% CI 0·47–0·80; figure 4). Over this period, at the predefined 60% threshold, RISK11 showed very low sensitivity of 25% (95% CI 12–46) with specificity of 91% (95% CI 91–91). At an exploratory RISK11 threshold of 26%, which provided 75% specificity, sensitivity was 47% (95% CI 26–74). By comparison, the prognostic sensitivity of IFNγ release assays over 15 months was 83% (62–100), but more than 60% of the population was IFNγ release assay positive (specificity 37%, 95% CI 35–40; table 2).Figure 4 Prognostic performance of RISK11 and treatment efficacy of 3HP
(A) ROC curve depicting RISK11 prognostic performance for incident tuberculosis through 15 months of follow-up. The shaded area represents 95% CI. The grey and black dots depict the minimum and optimal criteria, respectively, set out in the WHO target product profile for an incipient tuberculosis test. (B) RISK11 performance (area under the ROC curve) for endpoints within a 6-month sliding window from month 0 through 15. The shaded area represents 95% CI. (C) ROC curves depicting RISK11 prognostic performance for incident tuberculosis through expanding follow-up periods. The grey and black dots depict the minimum and optimal criteria, respectively, set out in the WHO target product profile for an incipient tuberculosis test. (D) Cumulative incidence of tuberculosis in RISK11-positive participants who were randomly assigned to 3HP (six cases, red line) and RISK11-positive participants who were randomly assigned to observation (14 cases, blue line) during follow-up. The shaded areas represent 95% CI. (E) Cumulative incidence of tuberculosis in participants who met criteria for treatment adherence per protocol, stratified into RISK11-positive participants who were randomly assigned to 3HP (four cases, red line) and RISK11-positive participants who were randomly assigned to observation (14 cases, blue line) during follow-up. (F) TE estimated through follow-up in participants who met criteria for treatment adherence per protocol. The shaded areas represent 95% CI. TRP=true positive rate. FPR=false positive rate. AUC=area under the receiver operating characteristic curve. TPP=target product profile. TE=treatment efficacy.
RISK11 prognostic performance was highly dependent on time to disease. Instantaneous RISK11 performance, estimated from 6-month sliding windows, showed prognostic discrimination was high (AUC >0·80) for approximately 9 months, before waning towards 0·58 between months 9 and 15 (figure 4; appendix p 16). Prognostic performance of RISK11 for incident tuberculosis within 6 months (AUC 0·95, 95% CI 0·92–1·0) exceeded the optimal TPP for an incipient tuberculosis test (appendix p 16), and for tuberculosis disease within 12 months (0·80, 0·65–0·94; figure 4) approached the minimum TPP (appendix p 16), but over a 15-month period did not meet minimum criteria for a prognostic tuberculosis test (table 2).
In the primary analysis of treatment efficacy among RISK11-positive participants, tuberculosis incidence in the 3HP-positive and 3HP-negative groups was 1·94 cases per 100 person years and 2·09 cases per 100 person years, respectively (figure 4; table 1), with estimated treatment efficacy of 7·0% (95% CI −145 to 64·7) over 15 months. In the subgroup of 286 adherent participants who completed at least 11 doses within 16 weeks, efficacy was 22% (−138 to 74; figure 4) over 15 months. Notably, among adherent participants, there were no tuberculosis cases through 9 months (figure 4).
Adverse events related to 3HP were mostly of mild to moderate severity (appendix p 12). 67 serious adverse events, including 29 due to trauma, occurred in 65 participants. Serious adverse events occurred in 20 (5·3%) of 375 RISK11-positive participants who received 3HP (eight serious adverse events due to trauma), compared with 12 (1·6%) of 764 in RISK11-positive and 3HP-negative participants (Fisher's exact p<0·001). Among RISK11-negative participants, 33 (1·9%) of 1784 experienced serious adverse events. All but two serious adverse events were deemed unrelated to 3HP. Serious adverse events related to 3HP included one hospitalisation for seizures (unintentional isoniazid overdose) and one death of unknown cause (possibly temporally related). One death of unknown cause also occurred in an untreated RISK11-negative participant. There were 16 deaths in total, including five RISK11-positive participants receiving 3HP (three deaths due to trauma), three untreated RISK11-positive participants, and eight RISK11-negative participants.
3HP was halted in 28 (7·5%) of 375 participants, due to an adverse event of special interest (influenza-like illness or other possible hypersensitivity reaction) in 17 (4·5%), hepatotoxicity in one (0·3%), gastrointestinal symptoms in three (0·8%), and seizures in three (0·8%) participants.
RISK11 diagnostic and prognostic performance and treatment efficacy of 3HP based on the secondary endpoint definition (at least one sputum sample; appendix p 14) are described in the appendix (p 15).
Five (8·2%) of the 61 participants witih prevalent tuberculosis were resistant to isoniazid or rifampicin, or both. Two (6·7%) of the 30 participants with incident tuberculosis, both in the untreated group, were resistant to isoniazid and rifampicin. No participants were observed to have drug-resistant incident tuberculosis in the 3HP-positive group.
Discussion
Our goal was to evaluate a biomarker-targeted, community-based strategy to detect missing tuberculosis cases among people who do not seek health care, whose disease might not be detected by symptom-focused screening algorithms, and to prevent disease among those at highest risk of progression to tuberculosis. The RISK11 assay was an effective screening test for active disease in symptomatic participants, in whom performance exceeded the requirements for a triage test, but less so in asymptomatic participants. The RISK11 signature was able to predict risk for tuberculosis disease progression, in a trial population with tuberculosis incidence exceeding one case per 100 person-years, but optimal prognostic performance was limited to a 6-month horizon. While risk-targeted 3HP did not prevent tuberculosis disease over 15 months, there was some evidence of transient efficacy through 9 months among fully adherent participants.
Community-based recruitment of ambulant volunteers was not focused on individuals with known risk factors for tuberculosis, such as household contact. Individuals with recent previous history of tuberculosis (>3 years before screening) and HIV infection were excluded. Nevertheless, more than 1% of study volunteers had previously undiagnosed, microbiologically confirmed tuberculosis at enrolment, based on spontaneous expectorated rather than induced sputum samples. More than 80% of these baseline tuberculosis cases did not have any symptom compatible with tuberculosis disease and would not have been detected by a tuberculosis screening strategy that requires symptoms as the entry point to investigation. This finding is consistent with 46–79% prevalence (median 50%) of subclinical tuberculosis reported in prevalence surveys.12, 13, 14 It is not known whether subclinical tuberculosis would have progressed to symptomatic disease, spontaneously halted, or even reversed if left untreated,15, 16 nor whether subclinical disease directly contributes to M tuberculosis transmission.17 Further research is needed to determine the importance of detection, treatment, and prevention of subclinical disease for global tuberculosis control.
Although very few prevalent tuberculosis cases were symptomatic, RISK11 performance for discrimination of symptomatic prevalent tuberculosis cases from symptomatic controls exceeded the optimal TPP criteria for a triage test, while not meeting the stringent criteria for a confirmatory diagnostic test.5 A 2020 prospective observational study among symptomatic individuals who self-presented to a tuberculosis clinic assessed diagnostic accuracy of 27 transcriptomic signatures for discrimination between prevalent tuberculosis cases and controls.18 The 16-gene Zak signature, from which RISK11 was derived, did not meet the minimum WHO criteria for a triage test, but four of the 27 signatures met these criteria, suggesting that another signature might perform as well as or better than RISK11. RISK11 discrimination of asymptomatic prevalent tuberculosis cases from asymptomatic controls was modest and did not meet the minimal criteria for a triage test. These findings suggest that host blood biomarker development must consider that subclinical tuberculosis might be characterised by more heterogenous or less pronounced peripheral blood inflammatory responses than symptomatic tuberculosis, or both, which affects RNA signature performance. This finding is consistent with lower inflammatory profiles, observed by blood transcriptomic and proteomic analyses, during the subclinical phases of tuberculosis progression compared with subsequent symptomatic, active disease.19, 20 The modest performance characteristics for asymptomatic prevalent tuberculosis would limit applicability of RISK11 for biomarker-targeted, mass community screening in the South African setting, where the majority of baseline tuberculosis cases were subclinical. A host blood biomarker with good sensitivity and specificity for symptomatic tuberculosis might be most useful in countries with low to medium tuberculosis burden, where individuals with compatible symptoms might not otherwise be investigated for tuberculosis. Future diagnostic studies in symptomatic patients seeking health care should also include patients with extrapulmonary and culture-negative tuberculosis, particularly in HIV-infected cohorts, and the full spectrum of differential diagnoses that commonly mimic tuberculosis.
Prognostic performance of RISK11 for risk of progression to incident tuberculosis was poor through 15 months and did not meet the minimum TPP criteria for an incipient tuberculosis test through this prognostic horizon.4 However, good prognostic performance was observed for incident tuberculosis within 12 months of testing and performance exceeded the optimal TPP criteria for tuberculosis occurring within 6 months of testing. The positive predictive value for incident disease (1·9 vs 0·9 for RISK11 compared with IFNγ release assay, respectively) was computed from the observed tuberculosis incidence rate, which was lower than that typically used in estimations (2%).3, 6 It is not possible to determine whether the late incident tuberculosis cases occurring among RISK11-negative participants were due to reactivation or new M tuberculosis infection. We infer that a prognostic test with optimal short-term performance might be useful in identifying people who would benefit from an efficacious intervention in a low-incidence setting, in which the timing of M tuberculosis exposure is often known and subsequent exposure is unlikely.
The 3HP regimen was previously shown to be as effective as 9 months of isoniazid in preventing tuberculosis among individuals with known exposure or positive TST.21 Ethical equipoise of the intervention and control groups in this trial was based on the fact that RISK11 had been validated in selected case-control studies, which can overestimate biomarker performance, and thus risk for tuberculosis among RISK11-positive individuals needed to be tested prospectively in the field. Furthermore, although TPT is given commonly to IFNγ release assay-positive and tuberculin skin test-positive individuals, and individuals with known household exposure to a tuberculosis patient, the vast majority do not progress to tuberculosis disease if left untreated. The risk–benefit balance of 3HP preventive therapy for RISK11-positive individuals was unknown. However, we found no evidence that 3HP treatment reduced the rate of incident tuberculosis over 15 months in RISK11-positive individuals, who might be further advanced along the spectrum of tuberculosis pathogenesis.19 Interpretation of the results is limited by the wide CIs. It is also notable that no tuberculosis cases were observed in fully adherent participants through 9 months. This finding is consistent with the possibility that 3HP was sufficient to temporarily halt, but insufficient to sterilise, incipient tuberculosis, resulting in reactivation. A RISK11-targeted preventive therapy strategy for high tuberculosis transmission settings like South Africa might require a more potent therapeutic regimen than 3HP. 3HP might have been sufficient to sterilise incipient tuberculosis disease, but not to protect against tuberculosis disease resulting from reinfection after completion of the treatment course. Although it is not possible to distinguish between reactivation and reinfection tuberculosis cases in this study, we suggest that the limited time available for reinfection and subsequent progression to disease after completing 3HP makes the latter possibility less likely.
The study was subject to a number of limitations. The hybrid design required an open-label treatment group,2 with no placebo for RISK11-positive participants, so that risk for tuberculosis could also be evaluated in the control group while concealing RISK11 status from participants, site staff, and tuberculosis endpoint laboratory staff for analysis of biomarker performance. Tuberculosis case accrual during the latter stages of follow-up suggested no evidence of ascertainment bias during treatment. Extensive study simulations were done to inform the size of each group for the coprimary analyses. However, due to lower than expected prevalence of RISK11-positive status in the screened population (9·3% vs 15%), enrolment of 1139 RISK11-positive individuals required 2 years, compared with planned enrolment of 1500 RISK11-positive individuals over 1 year. As a result, fewer than expected incident tuberculosis outcomes were observed (24 vs 40 primary endpoints), which might have reduced power for both treatment efficacy and RISK11 performance analyses. Not all participants in the treatment group completed 3HP per protocol, because study drug was discontinued for suspected hypersensitivity reactions or influenza-like illnesses. However, the discontinuation rate (7·5%) was comparable to other trials of 3HP, in which study drug was discontinued in 17·9% of participants overall and in 4·9% due to an adverse event.21 The loss to follow-up rate in this trial (14·4%) was higher than expected and might reflect the challenges of retaining the study participants, in the absence of traditional tuberculosis risk factors for which surveillance is routine. However, loss to follow-up occurred predominantly after the treatment period and did not seem to have been biased by treatment factors. We note that median duration of participation was 13·9 months and thus loss to follow-up did not have major unforeseen effect on statistical power. Strengths of the study include enrolment in geographically distinct sites across South Africa that were representative of populations with different rates of IFNγ release assay positivity and tuberculosis disease, which were congruent with local rates of RISK11 positivity, although the sample size was not sufficient for analysis of signature performance or 3HP efficacy at site level. The findings broadly reflect the South African tuberculosis epidemic, but might not be directly applicable to countries with much lower tuberculosis incidence.
It is not yet known whether other parsimonious tuberculosis signatures, developed and validated like RISK11 in carefully curated case-control studies, will exhibit similar performance characteristics when prospectively tested in the field, where undiagnosed subclinical tuberculosis might pose a challenge to diagnostic performance. Head-to-head analyses of several transcriptomic tuberculosis signatures with promising diagnostic performance are currently underway on CORTIS samples and novel near-patient testing platforms are in development, which might bring cost-effective, community-based tuberculosis biomarker screening closer to implementation in the field. However, although we have shown that a strategy of biomarker-guided tuberculosis preventive therapy is feasible, the optimal preventive therapy regimen for use in such a strategy remains elusive.
Data sharing
Deidentified RISK11 signature scores and primary tuberculosis endpoint data from all participants will be available with publication. The dataset is deposited in Zivahub (https://doi.org/10.25375/uct.13573337.v1), an open access data repository hosted by the University of Cape Town's institutional data repository powered by Figshare for Institutions.
Supplementary Material
Supplementary appendix
Acknowledgments
The trial was funded by the Bill & Melinda Gates Foundation (OPP1116632, OPP1137034) and the Strategic Health Innovation Partnerships Unit of the South African Medical Research Council with funds received from the South African Department of Science and Technology. Rifapentine was donated by the manufacturer (Sanofi). The authors thank the members of the data and safety monitoring board and the trial steering committee.
Contributors
TJS, AF-G, AP-N, SS, GW, KN, GC, and MH designed the study. CI, WB, AH, STM, RH-M, MT, GW, KN, and GC recruited and evaluated participants. TJS, AP-N, SKM, SCM, KH, MM, NB, ME, LJ, and RR collected and analysed laboratory data. AF-G, and BB accessed and verified the data. TJS, AF-G, AP-N, HM, BB, TS, RGW, and MH analysed data and interpreted results. KH, CH, and MK provided operational support. TJS, AF-G, HM, and MH drafted the Article. All authors had full access to the data, and reviewed, revised and gave final approval of the Article before submission.
The CORTIS-01 Study Team
Kesenogile Baepanye, Tshepiso Baepanye, Ken Clarke, Marelize Collignon, Audrey Dlamini, Candice Eyre, Tebogo Feni, Moogo Fikizolo, Phinda Galane, Thelma Goliath, Alia Gangat, Shirley Malefo-Grootboom, Elba Janse van Rensburg, Bonita Janse van Rensburg, Sophy Kekana, Marietjie Zietsman, Adrianne Kock, Israel Kunene, Aneessa Lakhi, Nondumiso Langa, Hilda Ledwaba, Marillyn Luphoko, Immaculate Mabasa, Dorah Mabe, Nkosinathi Mabuza, Molly Majola, Mantai Makhetha, Mpho Makoanyane, Blossom Makhubalo, Vernon Malay, Juanita Market, Selvy Matshego, Nontsikelelo Mbipa, Tsiamo Mmotsa, Sylvester Modipa, Samuel Mopati, Palesa Moswegu, Primrose Mothaga, Dorothy Muller, Grace Nchwe, Maryna Nel, Lindiwe Nhlangulela, Bantubonke Ntamo, Lawerence Ntoahae, Tedrius Ntshauba, Nomsa Sanyaka, Letlhogonolo Seabela, Pearl Selepe, Melissa Senne, MG Serake, Maria Thlapi, Vincent Tshikovhi, Lebogang Tswaile, Amanda van Aswegen, Lungile Mbata, Constance Takavamanya, Pedro Pinho, John Mdlulu, Marthinette Taljaard, Naydene Slabbert, Sharfuddin Sayed, Tanya Nielson, Melissa Senne, Ni Ni Sein, Lungile Mbata (The Aurum Institute); Dhineshree Govender, Tilagavathy Chinappa, Mbali Ignatia Zulu, Nonhle Bridgette Maphanga, Senzo Ralph Hlathi, Goodness Khanyisile Gumede, Thandiwe Yvonne Shezi, Jabulisiwe Lethabo Maphanga, Zandile Patrica Jali, Thobelani Cwele, Nonhlanhla Zanele Elsie Gwamanda, Celaphiwe Dlamini, Zibuyile Phindile Penlee Sing, Ntombozuko Gloria Ntanjana, Sphelele Simo Nzimande, Siyabonga Mbatha, Bhavna Maharaj, Atika Moosa, Cara-Mia Corris (Centre for the AIDS Programme of Research in South Africa); Fazlin Kafaar, Marwou De Kock, Hennie Geldenhuys, Angelique Kany Kany Luabeya, Justin Shenje, Natasja Botes, Susan Rossouw, Hadn Africa, Bongani Diamond, Samentra Braaf, Sonia Stryers, Alida Carstens, Ruwiyda Jansen, Simbarashe Mabwe, Roxane Herling, Ashley Veldsman, Lebohgang Makhete, Marcia Steyn, Sivuyile Buhlungu, Margareth Erasmus, Ilse Davids, Patiswa Plaatjie, Alessandro Companie, Frances Ratangee, Helen Veldtsman, Christel Petersen, Charmaine Abrahams, Miriam Moses, Xoliswa Kelepu, Yolande Gregg, Liticia Swanepoel, Nomsitho Magawu, Nompumelelo Cetywayo, Lauren Mactavie, Habibullah Valley, Elizabeth Filander, Nambitha Nqakala, Angelique Mouton, Fajwa Opperman, Elma Van Rooyen, Petrus Tyambetyu (South African Tuberculosis Vaccine Initiative, University of Cape Town); Elizna Maasdorp, Justine Khoury, Belinda Kriel, Bronwyn Smith, Liesel Muller, Susanne Tonsing, Andre Loxton, Andriette Hiemstra, Petri Ahlers, Marika Flinn (DST/NRF Centre of Excellence for Biomedical TB Research and SAMRC Centre for TB Research, Stellenbosch University); and Eva Chung, Michelle Chung, Alicia Sato (Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Research Center)
Declaration of interests
TJS has a patent of the RISK11 signature pending and reports grants from the Bill and Melinda Gates Foundation and South African Medical Research Council. KN reports grants from CAPRISA. GW reports a patent (PCT/IB2019/052043) pending to University of Cape Town, Stellenbosch University, Max-Planck-Gesellschaft Zur Foerderung Der Wissenschaften EV, Seattle Children's Hospital Doing Business as Seattle Children's Research Institute, and UK Research and Innovation. GC reports grants from the Bill & Melinda Gates Foundation. AP-N has a patent of the RISK11 signature pending and reports grants from the Bill & Melinda Gates Foundation and the South African Medical Research Council. MH reports grants from the Bill & Melinda Gates Foundation and the South African Medical Research Council. | ISONIAZID, PYRIDOXINE, RIFAPENTINE | DrugsGivenReaction | CC BY | 33508224 | 20,168,180 | 2021-03 |
Give an alphabetized list of all active substances of drugs taken by the patient who experienced 'Seizure'. | Biomarker-guided tuberculosis preventive therapy (CORTIS): a randomised controlled trial.
Targeted preventive therapy for individuals at highest risk of incident tuberculosis might impact the epidemic by interrupting transmission. We tested performance of a transcriptomic signature of tuberculosis (RISK11) and efficacy of signature-guided preventive therapy in parallel, using a hybrid three-group study design.
Adult volunteers aged 18-59 years were recruited at five geographically distinct communities in South Africa. Whole blood was sampled for RISK11 by quantitative RT-PCR assay from eligible volunteers without HIV, recent previous tuberculosis (ie, <3 years before screening), or comorbidities at screening. RISK11-positive participants were block randomised (1:2; block size 15) to once-weekly, directly-observed, open-label isoniazid and rifapentine for 12 weeks (ie, RISK11 positive and 3HP positive), or no treatment (ie, RISK11 positive and 3HP negative). A subset of eligible RISK11-negative volunteers were randomly assigned to no treatment (ie, RISK11 negative and 3HP negative). Diagnostic discrimination of prevalent tuberculosis was tested in all participants at baseline. Thereafter, prognostic discrimination of incident tuberculosis was tested in the untreated RISK11-positive versus RISK11-negative groups, and treatment efficacy in the 3HP-treated versus untreated RISK11-positive groups, during active surveillance through 15 months. The primary endpoint was microbiologically confirmed pulmonary tuberculosis. The primary outcome measures were risk ratio [RR] for tuberculosis of RISK11-positive to RISK11-negative participants, and treatment efficacy. This trial is registered with ClinicalTrials.gov, NCT02735590.
20 207 volunteers were screened, and 2923 participants were enrolled, including RISK11-positive participants randomly assigned to 3HP (n=375) or no 3HP (n=764), and 1784 RISK11-negative participants. Cumulative probability of prevalent or incident tuberculosis disease was 0·066 (95% CI 0·049 to 0·084) in RISK11-positive (3HP negative) participants and 0·018 (0·011 to 0·025) in RISK11-negative participants (RR 3·69, 95% CI 2·25-6·05) over 15 months. Tuberculosis prevalence was 47 (4·1%) of 1139 versus 14 (0·78%) of 1984 in RISK11-positive compared with RISK11-negative participants, respectively (diagnostic RR 5·13, 95% CI 2·93 to 9·43). Tuberculosis incidence over 15 months was 2·09 (95% CI 0·97 to 3·19) vs 0·80 (0·30 to 1·30) per 100 person years in RISK11-positive (3HP-negative) participants compared with RISK11-negative participants (cumulative incidence ratio 2·6, 95% CI 1·2 to 5·9). Serious adverse events related to 3HP included one hospitalisation for seizures (unintentional isoniazid overdose) and one death of unknown cause (possibly temporally related). Tuberculosis incidence over 15 months was 1·94 (95% CI 0·35 to 3·50) versus 2·09 (95% CI 0·97 to 3·19) per 100 person-years in 3HP-treated RISK11-positive participants compared with untreated RISK11-positive participants (efficacy 7·0%, 95% CI -145 to 65).
The RISK11 signature discriminated between individuals with prevalent tuberculosis, or progression to incident tuberculosis, and individuals who remained healthy, but provision of 3HP to signature-positive individuals after exclusion of baseline disease did not reduce progression to tuberculosis over 15 months.
Bill and Melinda Gates Foundation, South African Medical Research Council.
Introduction
Large-scale prevention of progression from Mycobacterium tuberculosis infection to tuberculosis disease is key to achieving WHO End TB Strategy targets, yet tuberculin skin tests (TST) and interferon (IFN) γ release assays have poor specificity for incident tuberculosis.1 A biomarker-targeted prevention strategy using a highly specific correlate of risk (COR) for incident tuberculosis, in tandem with effective short-course tuberculosis preventive therapy (TPT),2 might impact the epidemic by preventing incident tuberculosis disease before transmission.3 Modelling suggests a three-times reduction in burden of TPT if targeted by COR, compared with IFNγ release assays and TST.4 Furthermore, because active tuberculosis disease should be excluded before starting TPT, additional utility of the prognostic COR as a screening (triage) test to identify undiagnosed tuberculosis disease would allow earlier curative treatment. WHO and FIND have developed target product profiles (TPP) for triage tests for tuberculosis (optimal and minimum sensitivity of >95% and >90%, and specificity of >80% and >70%, respectively),5 and incipient tuberculosis tests (minimum sensitivity and specificity of 75% and 75%, and optimal sensitivity and specificity of 90% and 90%, respectively).6
Research in context
Evidence before this study
Host blood RNA signatures have potential as tuberculosis triage or diagnostic tests, and as predictive tests to target tuberculosis preventive therapy. We searched MEDLINE, Scopus, Web of Science, and EBSCO libraries for publications between Jan 1, 2005, and May 31, 2020, using the search terms “Tuberculosis” OR “TB” OR “Mycobacterium tuberculosis” OR “MTB” AND “diagnosis” OR “diagnostic” OR “detect” OR “predic”OR “prognosis” OR “prognostic” OR “screen” AND “Blood Biomarker” OR “blood biomarkers” OR “bio-signature” OR “gene expression” OR “genetic transcription” OR “host blood” OR “immune marker” OR “immunologic marker” OR “Ribonucleic Acid” OR “RNA” OR “signature” OR “surrogate endpoint” OR “surrogate marker” OR “transcriptome” OR “transcriptomic” AND “Area under curve” OR “AUC” OR “receiver operating characteristic” OR “ROC” OR “Accuracy” OR “Performance” OR “sensitivity” OR “specificity”. Studies comparing blood RNA signatures in individuals with tuberculosis versus Mycobacterium tuberculosis-uninfected controls, individuals with other respiratory diseases, or with M tuberculosis infection and using a microbiological reference standard of either sputum M tuberculosis culture, Xpert MTB/RIF, or smear microscopy for tuberculosis diagnosis, were included.
28 studies reported evaluation of 32 host blood RNA signatures for diagnosis or prediction of progression to tuberculosis disease in 83 cohorts. Only two studies prospectively tested performance of an RNA signature in all evaluable participants; the remainder used a case-control design. Multiple studies have tested tuberculosis preventive therapy in people with M tuberculosis latent tuberculosis infection. No studies have tested efficacy of tuberculosis preventive therapy to avert disease in RNA signature-positive people.
Added value of this study
This large randomised, controlled trial in five South African communities prospectively tested diagnostic and prognostic performance of an RNA signature (RISK11) in all evaluable participants, and estimated efficacy of tuberculosis preventive therapy to avert disease in RNA signature-positive people. More than 1% of HIV-uninfected community volunteers had previously undiagnosed, microbiologically confirmed tuberculosis at screening, more than 80% of which was asymptomatic. RISK11 showed moderate performance for tuberculosis triage, but good performance for diagnosis of symptomatic tuberculosis, and for short-term prediction of incident tuberculosis. 3 months of once-weekly, high-dose isoniazid and rifapentine (3HP) did not reduce incident disease in RISK11-positive individuals over 15 months of follow-up.
Implications of all the available evidence
Host blood biomarker development must consider that subclinical tuberculosis might be characterised by more heterogenous, or less pronounced blood inflammatory responses than symptomatic tuberculosis, or both, which will affect RNA signature performance. RISK11 might be better suited to screening of symptomatic individuals with possible tuberculosis than for mass community-based screening. RISK11 can identify those at highest risk for short-term progression to disease, but a more potent regimen than 3HP might be needed to prevent tuberculosis in RISK11-positive individuals.
We previously developed a 16-gene transcriptomic signature by whole blood RNA sequencing for identification of individuals at high risk of developing tuberculosis (the Zak16 signature).7, 8 Measurement of Zak16 was adapted to quantitative RT-PCR (RT-qPCR), and predictive ability for incident tuberculosis was validated in an independent longitudinal cohort of household contacts of tuberculosis patients.8 We reduced this signature to 11 genes (RISK11) with equivalent performance,9, 10 to allow testing in 96-well PCR format. Zak16 and RISK11 also did well as non-sputum screening tests for prevalent, active tuberculosis in case-control studies, measured by RNA sequencing, microarray,7, 8 or microfluidic RT-qPCR.9, 10 In a 2020 systematic review and patient-level pooled meta-analysis of 17 transcriptomic signatures for prognosis of incident tuberculosis, Zak16 was among eight signatures that achieved a positive predictive value above the WHO TPP benchmark for incipient tuberculosis tests.11 Since case-control studies might overestimate performance characteristics, testing in unselected populations is needed.
We report on a randomised controlled trial (CORTIS; NCT02735590), which prospectively measured diagnostic and prognostic performance of RISK11 for triage of prevalent and prediction of incident tuberculosis in South African adults; and, in parallel, estimated efficacy of short-course TPT to avert incident disease in RISK11-positive individuals.
Methods
Study design
This randomised controlled trial used a hybrid treatment selection, three-group study design to evaluate efficacy of the intervention and, in parallel, performance of the biomarker used to allocate that intervention (figure 1).2 The coprimary aims were to test, over 15 months, whether RISK11 status differentiates between people with and without cumulative prevalent or incident tuberculosis; and whether preventive therapy (weekly high-dose isoniazid and rifapentine for 12 weeks [3HP]) reduces tuberculosis incidence among RISK11-positive people compared with active surveillance only. RISK11 performance to detect prevalent tuberculosis was evaluated in all groups at baseline. RISK11 performance to predict incident tuberculosis was evaluated in the untreated RISK11-positive and RISK11-negative groups, and treatment efficacy was estimated from the 3HP treated and untreated RISK11-positive groups, after omitting participants with baseline tuberculosis. Efficiency of the hybrid study design was maximised by using the RISK11-positive and 3HP-negative group to evaluate both biomarker performance and treatment efficacy.Figure 1 Study design
The prevalence of RISK11 positivity was not precisely known in the study population; therefore, the number of individuals to be screened and the randomisation of RISK11-negative participants to enrolment was monitored and adjusted adaptively to ensure concurrent enrolment of the target number of RISK11-positive and RISK11-negative participants, per protocol specifications. The study used a three-group design to evaluate efficacy of the intervention and, in parallel, performance of the biomarker used to allocate that intervention. Diagnostic performance for differentiation of prevalent tuberculosis was tested in all three groups at baseline; prognostic performance for differentiation of incident tuberculosis over 15 months was tested in the two untreated groups (untreated RISK11 positive and untreated RISK11 negative); and treatment efficacy of 3HP over 15 months was tested in the two RISK11-positive groups (treated and untreated RISK11 positive). *Participants evaluated for eligibility at screening and enrolment. †Groups randomly assigned in blocks to ensure concurrent enrolment.
Routine implementation of TPT requires that patients are screened to exclude prevalent tuberculosis before TPT is provided to prevent incident disease. Therefore, because risk for prevalent and incident tuberculosis by RISK11 status must be understood before efficacy of preventive therapy against incident tuberculosis in RISK11-positive people can be interpreted, these secondary analyses are presented before the primary analysis of treatment efficacy.
The trial protocol (appendix p 21) was approved by the South African Health Products Regulatory Agency (20160305) by the Institutional Human Ethics Committees of participating sites; and was registered on ClinicalTrials.gov (NCT02735590). All participants provided written informed consent in their language of choice.
Participants
Adult volunteers living in tuberculosis-endemic communities in South Africa were recruited at five sites (South African Tuberculosis Vaccine Initiative, Worcester; Immunology Research Group, Stellenbosch University, Ravensmead; Aurum Institute, Klerksdorp and Rustenberg; and Centre for the AIDS Programme of Research in South Africa, Durban). Community-based recruitment was by word-of-mouth, house-to-house visits, and liaison with non-governmental organisations. Recruitment did not target groups at high risk of tuberculosis, such as household contacts. Eligible participants were aged between 18 years and 59 years, HIV-negative, without a history of tuberculosis disease in the last 3 years or preselected comorbidities (appendix p 8).
Screening
Venous blood was collected in PAXgene RNA tubes from all potentially eligible people at screening, frozen at −20°C, and shipped weekly to the South African Tuberculosis Vaccine Initiative Immunology Laboratory for RISK11 testing by qRT-PCR assay. Participants with a RISK11 score of at least 60% were classified a priori as RISK11 positive and less than 60% as RISK11 negative. This 60% threshold was the optimal point at which sensitivity and specificity for prognosis of incident tuberculosis were balanced in case-control studies.2 Samples with failed reference primer-probe reactions, with marked deviation in internal positive control sample from historical runs, or more than 30% failed interferon-stimulated genes primer-probe reactions (see quality control criteria and analysis script in Bitbucket instance) were classified as indeterminate. Per-participant qualitative results (RISK11 positive and RISK11 negative) were provided to the Triclinium Clinical Development (TCD) Data Centre for participant randomisation (see appendix pp 2–3).
Randomisation and masking
Assignment to study group was managed by an unmasked randomisation team from the TCD Data Centre, based on RISK11 status. RISK11-positive volunteers were randomly assigned (1:2; block size 15) to either open-label 3HP (3HP-positive group), or active tuberculosis surveillance without 3HP (3HP-negative group), in accordance with a randomisation schedule generated using SAS, version 9.4. RISK11-negative volunteers were concurrently randomly assigned either to active tuberculosis surveillance (3HP-negative group) or to non-participation, to enrich the study population for RISK11-positive participants.
Study group allocation was revealed to site staff after enrolment of eligible participants within 28 days of screening. The 3HP-negative group was double-blinded to RISK11 status, but unblinded to treatment allocation; the 3HP-positive group was unblinded to both RISK11-positive status and treatment allocation (figure 1). RISK11-positive participants randomly assigned to active surveillance did not receive a placebo, to maintain blinding of participants and study team members to RISK11 status.
Procedures
Target enrolment was maximally 3200 participants (1500 RISK11 positive and 1700 RISK11 negative). The randomisation ratio for RISK11-negative volunteers was adapted to ensure concurrent enrolment of the recruitment target. Adaptations occurred at intervals, informed by 3-monthly operational monitoring reports based on enrolment rate, RISK11-positive and RISK11-negative prevalence, and tuberculosis case accrual blinded to RISK11 status (appendix p 7).
Enrolment procedures included phlebotomy for IFNγ release assays (QuantiFERON TB Gold-Plus, Qiagen), tuberculosis symptom screen (a positive tuberculosis symptom screen included one or more symptoms of persistent unexplained cough, fever, night sweats, weight loss, or any haemoptysis), and collection of two spontaneous expectorated sputum samples for Xpert MTB/RIF assay (Cepheid) from all sputum-productive participants, regardless of symptoms.
All participants attended up to seven study visits, including four study site visits at months 3, 6, 12, and 15 (end of study), and three telephonic contact or field visits at months 1, 2, and 9. HIV testing was repeated at months 6 and 12.
Participants in the 3HP group received open-label, high-dose isoniazid (15 mg/kg; maximum dose 900 mg) with pyridoxine supplementation (25 mg) and rifapentine based on body weight (>32–50 kg, 750 mg; >50 kg, 900 mg), given weekly as directly observed oral doses, ideally with food, over 12 weeks. Completion of 3HP treatment was defined as receipt of 11 doses within 16 weeks (appendix p 3).
Outcomes
The two primary outcome measures were RISK11-positive to RISK11-negative risk ratio (RR) for prevalent or incident tuberculosis disease, and 3HP treatment efficacy through 15 months. Diagnostic performance for prevalent tuberculosis was evaluated on the presence of tuberculosis at the enrolment visit within the ITT cohort.
Participants in the 3HP group had each dose directly observed by study staff, and attended clinic for evaluation of solicited adverse events and possible adverse events of special interest at weeks 1–11. Solicited adverse events included gastrointestinal signs and symptoms suggestive of hepatotoxicity, such as nausea, vomiting, and jaundice. Possible hypersensitivity reactions, including influenza-like illness, were reported as adverse events of special interest. Safety events meeting the definition for a serious adverse event, whether deemed related or unrelated to study drug, were reported for both all participants through end of study.
Statistical analysis
The intention-to-treat (ITT) cohort included all enrolled participants who completed investigation for tuberculosis endpoints at baseline. The modified intention-to-treat (mITT) cohort included all participants in the ITT population who completed at least one post-baseline tuberculosis endpoint investigation and omitted participants with endpoint-defined tuberculosis disease at baseline (prevalent tuberculosis).
The diagnostic RR was estimated as a proportion of participants with tuberculosis disease among RISK11-positive divided by RISK11-negative participants. Prognostic performance for incident tuberculosis after enrolment was evaluated among 3HP-negative participants within the mITT cohort (ie, excluding participants with tuberculosis at baseline). Prognostic RR was estimated as the cumulative incidence through 15 months for RISK11-positive divided by RISK11-negative participants. The primary RR was an estimate of the probability of having prevalent tuberculosis or developing incident tuberculosis among RISK11-positive divided by RISK11-negative participants; this combined probability of prevalent and incident tuberculosis was computed for each group as the probability of prevalent tuberculosis plus the probability of incident tuberculosis through 15 months (conditioned on not having prevalent tuberculosis). Efficacy of 3HP preventive therapy to reduce the rate of incident tuberculosis disease compared with the untreated RISK11-positive participants was also evaluated in the mITT population. Treatment efficacy was estimated as one minus the cumulative incidence of RISK11-positive and 3HP-positive participants divided by RISK11-positive and 3HP-negative participants through 15 months. A per-protocol analysis of treatment efficacy was done and excluded RISK11-positive and 3HP-positive participants that received less than 11 of the 12 weekly doses of 3HP.
For statistical efficiency, a random subset of RISK11-negative participants were enrolled, therefore creating an ITT cohort artificially enriched with RISK11-positive participants. Therefore, unless stated otherwise, all analyses were adjusted so that results reflected the screened population. Secondary performance metrics such as sensitivity and specificity were estimated using standard formulas with binary endpoints; a percentile bootstrap with 20 000 samples was used to estimate 95% CIs. For descriptive analyses (Table 1, Table 2), rank-based Wilcoxon rank-sum tests were used to compare continuous variables in RISK11-positive versus RISK11-negative groups. Fisher's exact test was used to compare binary readouts; p values in Table 1, Table 2 were not adjusted for multiple comparisons. The prespecified statistical analysis plan is included in the appendix (p 82) and contains detailed description of the statistical methods.Table 1 Baseline characteristics and primary tuberculosis endpoints by group
Total (n=2923) RISK11 positive and 3HP positive (n=375) RISK11 positive and 3HP negative (n=764) RISK11 negative (n=1784) RISK11 positive vs RISK11 negative, p value*
Sex
Female 1585 (54·2%) 213 (56·8%) 469 (61·4%) 903 (50·6%) <0·001
Male 1338 (45·8%) 162 (43·2%) 295 (38·6%) 881 (49·4%) ..
Age, years 28·5 (9·0) 28·8 (9·5) 28·4 (9·2) 28·4 (8·7) 0·541
Race or ethnicity
Asian 4 (0·1%) 0 1 (0·1%) 3 (0·2%) 0·567
Black African 1947 (66·6%) 227 (60·5%) 477 (62·4%) 1243 (69·7%) <0·001
White 4 (0·1%) 0 1 (0·1%) 3 (0·2%) 0·567
Mixed race 968 (33·1%) 148 (39·5%) 285 (37·3%) 535 (30·0%) <0·001
Body-mass index, kg/m2 24·6 (7·7) 24·1 (6·3) 24·4 (6·1) 24·9 (8·6) 0·354
Previous tuberculosis 230 (7·9%) 36 (9·6%) 75 (9·8%) 119 (6·7%) 0·003
Smoking 1478 (50·6%) 203 (54·1%) 391 (51·2%) 884 (49·6%) 0·170
Family tuberculosis history 462 (15·8%) 66 (17·6%) 110 (14·4%) 286 (16·0%) 0·675
Interferon γ release assay positive 1895 (64·8%) 250 (66·7%) 528 (69·1%) 1117 (62·6%) <0·001
Follow-up, months 15 (9·4–15·0) 15 (11·1–15·0) 15 (9·1–15·0) 13·6 (9·4–15·0) 0·056
Prevalent tuberculosis, n (probability, 95% CI) 61 (1·1%, 0·77–1·6)† 47 (4·1%, 3·1–5·4)‡ 47 (4·1%, 3·1–5·4)§ 14 (0·78%, 0·47–1·3) NA
Incident tuberculosis, n (cases per 100 person years, 95% CI) 24 (1·05, 0·59–1·5)§ 6 (1·9, 0·35–3·5) 14 (2·09, 0·97–3·19) 10 (0·80, 0·30–1·30) NA
Cumulative tuberculosis, n (probability, 95% CI)¶ 85 (0·022, 0·016–0·028)† 61 (0·066, 0·049–0·084)‖** 61 (0·066, 0·049–0·084)** 24 (0·018, 0·011–0·026) NA
Data are n (%), mean (SD), or median (IQR), unless stated otherwise. Secondary tuberculosis endpoints by group are in the appendix (p 13). NA=not applicable.
* For continuous data, p values from Wilcoxon rank sum test. For categorical data, p values from Fischer's exact test.
† Overall rate estimates are weighted combinations of the enrolled participants to reflect the screened population.
‡ Overall incidence and cumulative tuberculosis excludes RISK11-positive and 3HP-positive incident cases.
§ Prevalent tuberculosis among RISK11 positive was assessed by combining the 3HP-negative and 3HP-positive groups. Value is repeated for RISK11 positive and 3HP positive, and RISK11 positive and 3HP negative.
¶ Probability of observing prevalent or incident tuberculosis over 15 months.
‖ Probability of prevalent or incident tuberculosis not estimated for RISK11-positive and 3HP-positive because it would combine data from before and after 3HP treatment and is therefore potentially misleading.
** Estimate for RISK11 positive includes 3HP-positive prevalent cases and 3HP-negative prevalent and incident cases. Value is repeated for RISK11 positive and 3HP positive, and RISK11 positive and 3HP negative.
Table 2 Performance of RISK11 and IGRA for prevalent and incident tuberculosis
Prevalent tuberculosis (ITT cohort) Incident tuberculosis (mITT cohort)*
RISK11 (60)† RISK11 (26)† IGRA RISK11 (60)† RISK11 (26)† IGRA
Risk ratio 5·13 (2·93 to 9·43) 7·39 (3·46 to 25·69) 4·43 (1·93 to 14·18) 2·61 (1·15 to 5·94) 2·67 (1·04 to 8·66) 2·83 (0·95 to 99·79)
Biomarker prevalence 9·2% (9·2 to 9·2) 25·8% (24·1 to 27·4) 63·4% (61·3 to 65·4) 9·0% (9·0 to 9·0) 25·3% (23·7 to 26·9) 63·2% (61·1 to 65·3)
AUC‡ 0·77 (0·68 to 0·86) .. 0·66 (0·58 to 0·73) 0·63 (0·47 to 0·80) .. 0·67 (0·54 to 0·79)
Sensitivity 34·9% (23·7 to 52·2) 72·1% (54·5 to 90·2) 88·7% (77·1 to 96·4) 25·0% (12·7 to 45·9) 47·5% (25·9 to 75·0) 83·2% (61·9 to 100·0)
Specificity 91·0% (90·9 to 91·1) 74·7% (73·1 to 76·4) 36·9% (34·9 to 39·0) 91·1% (91·0 to 91·2) 74·9% (73·2 to 76·5) 37·0% (34·9 to 39·1)
PPV§ 4·1% (3·0 to 5·4) 3·1% (2·0 to 4·3) 1·5% (1·0 to 2·2) 1·9% (0·9 to 3·0) 1·3% (0·6 to 2·1) 0·9% (0·5 to 1·4)
PPV (2% incidence)¶ .. .. .. 6·7% (3·5 to 11·8) 4·6% (2·5 to 7·1) 3·3% (2·5 to 3·9)
NPV§ 99·2% (98·8 to 99·6) 99·6% (99·2 to 99·9) 99·7% (99·3 to 99·9) 99·4% (99·0 to 99·8) 99·5% (99·1 to 99·9) 99·7% (99·2 to 100·0)
NPV (2% incidence)¶ .. .. .. 97·9% (97·6 to 98·5) 98·2% (97·5 to 99·2) 98·8% (97·4 to 100·0)
NNS or NNT‖ 29·9 (21·8 to 46·6) 37·8 (25·5 to 65·7) 83·1 (53·2 to 179·8) 75·1 (40·4 to 277·5) 123·8 (47·2 to 834·1) 168 (−440 to 1059)
Data are risk ratio (95 %CI), % (95% CI), AUC (95% CI), or NNS or NNT (95% CI). ITT=intention to treat. mITT=modified intention-to-treat. IGRA=interferon γ release assay. AUC=area under the receiver operating characteristic curve. PPV=positive predictive value. NPV=negative predictive value. NNS=number needed to screen. NNT=number needed to treat.
* Computed over 15-month prognostic window. Performance of RISK11 and IGRA for incident tuberculosis over 6-month and 12-month prognostic windows is in the appendix (p 16).
† RISK11 score threshold at 60% or 26%.
‡ AUC is computed across all score thresholds and value is presented under RISK11 (60).
§ Computed using the prevalence and incidence rates in the trial population as appropriate.
¶ Computed assuming 2% annual incidence of tuberculosis in the population.
‖ NNS for prevalent tuberculosis; NNT for incident tuberculosis. Performance of RISK11 and IGRA for prevalent and incident tuberculosis based on secondary endpoint (≥1 sample+) is in the appendix (p 15).
The study was designed to have 90% power to reject the null hypothesis of a RISK11-positive and RISK11-negative cumulative risk ratio less than 2 with one-sided alpha of 0·025. For treatment efficacy there was 80% power to reject the null hypothesis of efficacy less than 20%, with one-sided alpha of 0·05 and under the alternative design hypothesis that efficacy was 80%. To compute statistical power for these aims, a stochastic simulation of the trial was constructed, based on which we expected to observe 33 tuberculosis disease endpoints among 1500 RISK11-positive participants and seven tuberculosis disease endpoints among 1700 RISK11-negative participants (appendix p 6).
Role of the funding source
The trial was funded by the Bill & Melinda Gates Foundation (OPP1116632, OPP1137034) and the Strategic Health Innovation Partnerships Unit of the South African Medical Research Council, with funds received from the South African Department of Science and Technology. The Gates Foundation contributed to the study design. The regulatory sponsor was the University of Cape Town. Rifapentine (PRIFTIN) was donated by the manufacturer (Sanofi), who had no role in the design, implementation, analysis, or reporting of the trial. All authors had access to all the data reported in the study. The corresponding author had final responsibility for the decision to submit for publication.
Results
Between Sept 20, 2016, and Oct 19, 2018, 20 207 volunteers consented to participation; 16 248 met inclusion criteria at screening and 15 777 with a RISK11 result were potentially eligible for enrolment (figure 2). Of the 20 207 adults assessed for eligibility, common reasons for exclusion included HIV infection (1246 [6·1%]) and comorbid conditions (1369 [6·8%]; appendix p 8). 2923 eligible participants were enrolled after randomisation (1784 [61·0%] RISK11 negative and 1139 [39·0%] RISK11 positive; table 1).Figure 2 Trial profile
ITT=intention to treat. mITT=modified intention to treat. LTFU=lost to follow-up. PP=per protocol analysis. *585 participants did not complete the trial for reasons including: 53 (9%) pregnancies, 22 (4%) investigator withdrawals, 46 (8%) consent withdrawals, 26 (4%) HIV infections, 422 (72%) LTFU, and 16 (3%) deaths.
Participants were enrolled at five geographically diverse sites across South Africa (appendix pp 9–11). Among participants with a RISK11 result, 1434 (9·3%) of 15 494 were RISK11 positive, with the proportion ranging from 6·2% to 13·0% across the five sites. RISK11-positive participants were randomly asigned either to receive treatment (375 [32·9%] RISK11 positive and 3HP positive) or undergo observation without treatment (764 [67·1%] RISK11 positive and 3HP negative).
There were no significant differences in smoking history, family history of tuberculosis, or febrile illness between RISK11-positive and RISK11-negative participants (table 1). A higher proportion of RISK11-positive (75 [9·8%] of 364) than RISK11-negative (119 [6·7%] of 1784) participants reported previous tuberculosis disease (p=0·003). Compared with RISK11 negative participants, a greater proportion of RISK11-positive participants were female and mixed race (p<0·001; table 1).
Median duration of follow-up for incident tuberculosis was 13·9 months (IQR 9·0–15·0) and 1879 (66%) of 2500 3HP-negative mITT participants attended at least six scheduled visits. 1416 (49%) of 2838 participants were followed up for 15 months and 2160 (75%) of 2838 participants were followed up for at least 9 months. 585 (21%) of 2838 participants did not complete the study because of withdrawal, death, or loss to follow-up (figure 2; table 1).
Among 91 participants with tuberculosis who reached the primary endpoint, 61 were diagnosed with prevalent tuberculosis at baseline (47 RISK11 positive and 14 RISK11 negative; table 1; appendix p 13). Prevalence of tuberculosis in RISK11-positive and RISK11-negative participants was 4·1% (95% CI 3·1–5·4) and 0·78% (0·5–1·3), respectively (figure 3). Thereafter, 24 participants in the untreated group were diagnosed with incident tuberculosis disease (14 RISK11 positive and ten RISK11 negative; table 1; appendix p 13) with overall incidence of 1·05 cases (95% CI 0·59–1·5) per 100 person-years.Figure 3 RISK11 detection of combined prevalent and incident tuberculosis and diagnostic performance
(A) Prevalence of tuberculosis in RISK11-positive (47 cases,) and RISK11-negative (14 cases, red bar) participants at trial enrolment. Error bars depict 95% CI. Cumulative incidence probability of tuberculosis in RISK11-positive (14 cases, blue line) or RISK11-negative (10 cases, red line) mITT participants during follow-up. Shaded areas represent 95% CI. (B) Ratio of RISK11-positive versus RISK11 negative cumulative incidence probability of observing prevalent or incident tuberculosis disease, in the ITT population of the observation group. (C) RISK11 signature scores (each dot represents a participant) measured at screening in trial participants, stratified on tuberculosis diagnosis. Boxes depict IQR, midline represents the median, and whiskers indicate range among enrolled participants. (D) RISK11 signature scores measured at screening in prevalent tuberculosis cases with or without any tuberculosis symptoms, in incident tuberculosis cases or those who did not have a tuberculosis diagnosis. The enrolled population, not the screened population, is represented in (C) and (D), because a large fraction of RISK11-negative participants were not enrolled by design. (E) ROC curves depicting RISK11 diagnostic performance for prevalent tuberculosis in the ITT population, for prevalent tuberculosis among individuals with no symptoms of tuberculosis (asymptomatic) and among individuals with at least one symptom consistent with tuberculosis disease (symptomatic). Shaded areas represent the 95% CI. The grey and black dots indicate the minimum and optimal criteria, respectively, set out in the WHO target product profile for a triage test. The empty dot indicates the criteria set out in the WHO target product profile for a confirmatory diagnostic test. TRP=true positive rate. ITT=intention to treat. FPR=false positive rate. AUC=area under the receiver operating characteristic curve.
In the primary analysis of biomarker performance for cumulative tuberculosis, cumulative probability of observing prevalent or incident tuberculosis disease in the ITT population was 0·066 (95% CI 0·049–0·084) in RISK11-positive participants and 0·018 (0·011–0·025) in RISK11-negative participants, with a risk ratio of 3·69 (95% CI 2·25–6·05) over 15 months (figure 3).
A wide range of RISK11 scores was observed, irrespective of tuberculosis outcome (figure 3). Among enrolled participants, those who remained tuberculosis free (controls) had significantly lower RISK11 scores (24·2%, IQR 8·2–75·3) than those with prevalent or incident tuberculosis disease (76·7%, 36·6–94·4; Wilcoxon rank-sum test p<0·0001; figure 3).
In the secondary analysis of biomarker performance for prevalent tuberculosis, using the prespecified RISK11 test threshold (60%) there was 5·13-times (95% CI 3·01–10·69) increased risk of prevalent tuberculosis disease at baseline in RISK11-positive versus RISK11-negative participants, with sensitivity of 35% (95% CI 24–52) and specificity of 91% (95% CI 91–91; table 2). The receiver operating characteristic (ROC) analysis (figure 3) showed that a RISK11 threshold of 26% provided sensitivity of 72% (95% CI 54–90) and specificity of 75% (95% CI 73–76; table 2); with area under the diagnostic ROC curve (AUC) of 0·77 (95% CI 0·68–0·86). These performance estimates did not meet the minimum criteria for a tuberculosis triage test (table 2). 50 (83·6%) of 61 participants with prevalent tuberculosis had no symptoms compatible with tuberculosis disease, and the remaining 11 participants with at least one symptom consistent with tuberculosis had RISK11 scores of more than 80% (median 96%; figure 3; appendix p 14). Discrimination between symptomatic prevalent tuberculosis and symptomatic controls was high (AUC 0·97, 95% CI 0·95–0·99; figure 3) and, with a highly specific threshold, performance exceeded the optimal TPP for a tuberculosis triage test in this population. By contrast, RISK11 discriminated between asymptomatic controls and asymptomatic prevalent tuberculosis cases with an AUC of 0·75 (95% CI 0·66–0·84; figure 3).
In the secondary analysis of biomarker performance for incident tuberculosis, annualised incidence was 2·1 versus 0·8 per 100 person-years among the RISK11-positive versus RISK11-negative participants, respectively, which was equivalent to a 0·026 (95% CI 0·01–0·04) versus 0·010 (0·004–0·02) cumulative incident probability of developing tuberculosis disease over 15 months, respectively (figure 3). No incident tuberculosis cases were detected in RISK11-negative participants until 8·7 months (figure 3). Tuberculosis incidence through 15 months among RISK11-positive participants was 2·61 (95% CI 1·15–5·94) times higher than RISK11-negative participants (table 2); and the RISK11 signature discriminated between incident tuberculosis cases and controls with AUC of 0·63 (95% CI 0·47–0·80; figure 4). Over this period, at the predefined 60% threshold, RISK11 showed very low sensitivity of 25% (95% CI 12–46) with specificity of 91% (95% CI 91–91). At an exploratory RISK11 threshold of 26%, which provided 75% specificity, sensitivity was 47% (95% CI 26–74). By comparison, the prognostic sensitivity of IFNγ release assays over 15 months was 83% (62–100), but more than 60% of the population was IFNγ release assay positive (specificity 37%, 95% CI 35–40; table 2).Figure 4 Prognostic performance of RISK11 and treatment efficacy of 3HP
(A) ROC curve depicting RISK11 prognostic performance for incident tuberculosis through 15 months of follow-up. The shaded area represents 95% CI. The grey and black dots depict the minimum and optimal criteria, respectively, set out in the WHO target product profile for an incipient tuberculosis test. (B) RISK11 performance (area under the ROC curve) for endpoints within a 6-month sliding window from month 0 through 15. The shaded area represents 95% CI. (C) ROC curves depicting RISK11 prognostic performance for incident tuberculosis through expanding follow-up periods. The grey and black dots depict the minimum and optimal criteria, respectively, set out in the WHO target product profile for an incipient tuberculosis test. (D) Cumulative incidence of tuberculosis in RISK11-positive participants who were randomly assigned to 3HP (six cases, red line) and RISK11-positive participants who were randomly assigned to observation (14 cases, blue line) during follow-up. The shaded areas represent 95% CI. (E) Cumulative incidence of tuberculosis in participants who met criteria for treatment adherence per protocol, stratified into RISK11-positive participants who were randomly assigned to 3HP (four cases, red line) and RISK11-positive participants who were randomly assigned to observation (14 cases, blue line) during follow-up. (F) TE estimated through follow-up in participants who met criteria for treatment adherence per protocol. The shaded areas represent 95% CI. TRP=true positive rate. FPR=false positive rate. AUC=area under the receiver operating characteristic curve. TPP=target product profile. TE=treatment efficacy.
RISK11 prognostic performance was highly dependent on time to disease. Instantaneous RISK11 performance, estimated from 6-month sliding windows, showed prognostic discrimination was high (AUC >0·80) for approximately 9 months, before waning towards 0·58 between months 9 and 15 (figure 4; appendix p 16). Prognostic performance of RISK11 for incident tuberculosis within 6 months (AUC 0·95, 95% CI 0·92–1·0) exceeded the optimal TPP for an incipient tuberculosis test (appendix p 16), and for tuberculosis disease within 12 months (0·80, 0·65–0·94; figure 4) approached the minimum TPP (appendix p 16), but over a 15-month period did not meet minimum criteria for a prognostic tuberculosis test (table 2).
In the primary analysis of treatment efficacy among RISK11-positive participants, tuberculosis incidence in the 3HP-positive and 3HP-negative groups was 1·94 cases per 100 person years and 2·09 cases per 100 person years, respectively (figure 4; table 1), with estimated treatment efficacy of 7·0% (95% CI −145 to 64·7) over 15 months. In the subgroup of 286 adherent participants who completed at least 11 doses within 16 weeks, efficacy was 22% (−138 to 74; figure 4) over 15 months. Notably, among adherent participants, there were no tuberculosis cases through 9 months (figure 4).
Adverse events related to 3HP were mostly of mild to moderate severity (appendix p 12). 67 serious adverse events, including 29 due to trauma, occurred in 65 participants. Serious adverse events occurred in 20 (5·3%) of 375 RISK11-positive participants who received 3HP (eight serious adverse events due to trauma), compared with 12 (1·6%) of 764 in RISK11-positive and 3HP-negative participants (Fisher's exact p<0·001). Among RISK11-negative participants, 33 (1·9%) of 1784 experienced serious adverse events. All but two serious adverse events were deemed unrelated to 3HP. Serious adverse events related to 3HP included one hospitalisation for seizures (unintentional isoniazid overdose) and one death of unknown cause (possibly temporally related). One death of unknown cause also occurred in an untreated RISK11-negative participant. There were 16 deaths in total, including five RISK11-positive participants receiving 3HP (three deaths due to trauma), three untreated RISK11-positive participants, and eight RISK11-negative participants.
3HP was halted in 28 (7·5%) of 375 participants, due to an adverse event of special interest (influenza-like illness or other possible hypersensitivity reaction) in 17 (4·5%), hepatotoxicity in one (0·3%), gastrointestinal symptoms in three (0·8%), and seizures in three (0·8%) participants.
RISK11 diagnostic and prognostic performance and treatment efficacy of 3HP based on the secondary endpoint definition (at least one sputum sample; appendix p 14) are described in the appendix (p 15).
Five (8·2%) of the 61 participants witih prevalent tuberculosis were resistant to isoniazid or rifampicin, or both. Two (6·7%) of the 30 participants with incident tuberculosis, both in the untreated group, were resistant to isoniazid and rifampicin. No participants were observed to have drug-resistant incident tuberculosis in the 3HP-positive group.
Discussion
Our goal was to evaluate a biomarker-targeted, community-based strategy to detect missing tuberculosis cases among people who do not seek health care, whose disease might not be detected by symptom-focused screening algorithms, and to prevent disease among those at highest risk of progression to tuberculosis. The RISK11 assay was an effective screening test for active disease in symptomatic participants, in whom performance exceeded the requirements for a triage test, but less so in asymptomatic participants. The RISK11 signature was able to predict risk for tuberculosis disease progression, in a trial population with tuberculosis incidence exceeding one case per 100 person-years, but optimal prognostic performance was limited to a 6-month horizon. While risk-targeted 3HP did not prevent tuberculosis disease over 15 months, there was some evidence of transient efficacy through 9 months among fully adherent participants.
Community-based recruitment of ambulant volunteers was not focused on individuals with known risk factors for tuberculosis, such as household contact. Individuals with recent previous history of tuberculosis (>3 years before screening) and HIV infection were excluded. Nevertheless, more than 1% of study volunteers had previously undiagnosed, microbiologically confirmed tuberculosis at enrolment, based on spontaneous expectorated rather than induced sputum samples. More than 80% of these baseline tuberculosis cases did not have any symptom compatible with tuberculosis disease and would not have been detected by a tuberculosis screening strategy that requires symptoms as the entry point to investigation. This finding is consistent with 46–79% prevalence (median 50%) of subclinical tuberculosis reported in prevalence surveys.12, 13, 14 It is not known whether subclinical tuberculosis would have progressed to symptomatic disease, spontaneously halted, or even reversed if left untreated,15, 16 nor whether subclinical disease directly contributes to M tuberculosis transmission.17 Further research is needed to determine the importance of detection, treatment, and prevention of subclinical disease for global tuberculosis control.
Although very few prevalent tuberculosis cases were symptomatic, RISK11 performance for discrimination of symptomatic prevalent tuberculosis cases from symptomatic controls exceeded the optimal TPP criteria for a triage test, while not meeting the stringent criteria for a confirmatory diagnostic test.5 A 2020 prospective observational study among symptomatic individuals who self-presented to a tuberculosis clinic assessed diagnostic accuracy of 27 transcriptomic signatures for discrimination between prevalent tuberculosis cases and controls.18 The 16-gene Zak signature, from which RISK11 was derived, did not meet the minimum WHO criteria for a triage test, but four of the 27 signatures met these criteria, suggesting that another signature might perform as well as or better than RISK11. RISK11 discrimination of asymptomatic prevalent tuberculosis cases from asymptomatic controls was modest and did not meet the minimal criteria for a triage test. These findings suggest that host blood biomarker development must consider that subclinical tuberculosis might be characterised by more heterogenous or less pronounced peripheral blood inflammatory responses than symptomatic tuberculosis, or both, which affects RNA signature performance. This finding is consistent with lower inflammatory profiles, observed by blood transcriptomic and proteomic analyses, during the subclinical phases of tuberculosis progression compared with subsequent symptomatic, active disease.19, 20 The modest performance characteristics for asymptomatic prevalent tuberculosis would limit applicability of RISK11 for biomarker-targeted, mass community screening in the South African setting, where the majority of baseline tuberculosis cases were subclinical. A host blood biomarker with good sensitivity and specificity for symptomatic tuberculosis might be most useful in countries with low to medium tuberculosis burden, where individuals with compatible symptoms might not otherwise be investigated for tuberculosis. Future diagnostic studies in symptomatic patients seeking health care should also include patients with extrapulmonary and culture-negative tuberculosis, particularly in HIV-infected cohorts, and the full spectrum of differential diagnoses that commonly mimic tuberculosis.
Prognostic performance of RISK11 for risk of progression to incident tuberculosis was poor through 15 months and did not meet the minimum TPP criteria for an incipient tuberculosis test through this prognostic horizon.4 However, good prognostic performance was observed for incident tuberculosis within 12 months of testing and performance exceeded the optimal TPP criteria for tuberculosis occurring within 6 months of testing. The positive predictive value for incident disease (1·9 vs 0·9 for RISK11 compared with IFNγ release assay, respectively) was computed from the observed tuberculosis incidence rate, which was lower than that typically used in estimations (2%).3, 6 It is not possible to determine whether the late incident tuberculosis cases occurring among RISK11-negative participants were due to reactivation or new M tuberculosis infection. We infer that a prognostic test with optimal short-term performance might be useful in identifying people who would benefit from an efficacious intervention in a low-incidence setting, in which the timing of M tuberculosis exposure is often known and subsequent exposure is unlikely.
The 3HP regimen was previously shown to be as effective as 9 months of isoniazid in preventing tuberculosis among individuals with known exposure or positive TST.21 Ethical equipoise of the intervention and control groups in this trial was based on the fact that RISK11 had been validated in selected case-control studies, which can overestimate biomarker performance, and thus risk for tuberculosis among RISK11-positive individuals needed to be tested prospectively in the field. Furthermore, although TPT is given commonly to IFNγ release assay-positive and tuberculin skin test-positive individuals, and individuals with known household exposure to a tuberculosis patient, the vast majority do not progress to tuberculosis disease if left untreated. The risk–benefit balance of 3HP preventive therapy for RISK11-positive individuals was unknown. However, we found no evidence that 3HP treatment reduced the rate of incident tuberculosis over 15 months in RISK11-positive individuals, who might be further advanced along the spectrum of tuberculosis pathogenesis.19 Interpretation of the results is limited by the wide CIs. It is also notable that no tuberculosis cases were observed in fully adherent participants through 9 months. This finding is consistent with the possibility that 3HP was sufficient to temporarily halt, but insufficient to sterilise, incipient tuberculosis, resulting in reactivation. A RISK11-targeted preventive therapy strategy for high tuberculosis transmission settings like South Africa might require a more potent therapeutic regimen than 3HP. 3HP might have been sufficient to sterilise incipient tuberculosis disease, but not to protect against tuberculosis disease resulting from reinfection after completion of the treatment course. Although it is not possible to distinguish between reactivation and reinfection tuberculosis cases in this study, we suggest that the limited time available for reinfection and subsequent progression to disease after completing 3HP makes the latter possibility less likely.
The study was subject to a number of limitations. The hybrid design required an open-label treatment group,2 with no placebo for RISK11-positive participants, so that risk for tuberculosis could also be evaluated in the control group while concealing RISK11 status from participants, site staff, and tuberculosis endpoint laboratory staff for analysis of biomarker performance. Tuberculosis case accrual during the latter stages of follow-up suggested no evidence of ascertainment bias during treatment. Extensive study simulations were done to inform the size of each group for the coprimary analyses. However, due to lower than expected prevalence of RISK11-positive status in the screened population (9·3% vs 15%), enrolment of 1139 RISK11-positive individuals required 2 years, compared with planned enrolment of 1500 RISK11-positive individuals over 1 year. As a result, fewer than expected incident tuberculosis outcomes were observed (24 vs 40 primary endpoints), which might have reduced power for both treatment efficacy and RISK11 performance analyses. Not all participants in the treatment group completed 3HP per protocol, because study drug was discontinued for suspected hypersensitivity reactions or influenza-like illnesses. However, the discontinuation rate (7·5%) was comparable to other trials of 3HP, in which study drug was discontinued in 17·9% of participants overall and in 4·9% due to an adverse event.21 The loss to follow-up rate in this trial (14·4%) was higher than expected and might reflect the challenges of retaining the study participants, in the absence of traditional tuberculosis risk factors for which surveillance is routine. However, loss to follow-up occurred predominantly after the treatment period and did not seem to have been biased by treatment factors. We note that median duration of participation was 13·9 months and thus loss to follow-up did not have major unforeseen effect on statistical power. Strengths of the study include enrolment in geographically distinct sites across South Africa that were representative of populations with different rates of IFNγ release assay positivity and tuberculosis disease, which were congruent with local rates of RISK11 positivity, although the sample size was not sufficient for analysis of signature performance or 3HP efficacy at site level. The findings broadly reflect the South African tuberculosis epidemic, but might not be directly applicable to countries with much lower tuberculosis incidence.
It is not yet known whether other parsimonious tuberculosis signatures, developed and validated like RISK11 in carefully curated case-control studies, will exhibit similar performance characteristics when prospectively tested in the field, where undiagnosed subclinical tuberculosis might pose a challenge to diagnostic performance. Head-to-head analyses of several transcriptomic tuberculosis signatures with promising diagnostic performance are currently underway on CORTIS samples and novel near-patient testing platforms are in development, which might bring cost-effective, community-based tuberculosis biomarker screening closer to implementation in the field. However, although we have shown that a strategy of biomarker-guided tuberculosis preventive therapy is feasible, the optimal preventive therapy regimen for use in such a strategy remains elusive.
Data sharing
Deidentified RISK11 signature scores and primary tuberculosis endpoint data from all participants will be available with publication. The dataset is deposited in Zivahub (https://doi.org/10.25375/uct.13573337.v1), an open access data repository hosted by the University of Cape Town's institutional data repository powered by Figshare for Institutions.
Supplementary Material
Supplementary appendix
Acknowledgments
The trial was funded by the Bill & Melinda Gates Foundation (OPP1116632, OPP1137034) and the Strategic Health Innovation Partnerships Unit of the South African Medical Research Council with funds received from the South African Department of Science and Technology. Rifapentine was donated by the manufacturer (Sanofi). The authors thank the members of the data and safety monitoring board and the trial steering committee.
Contributors
TJS, AF-G, AP-N, SS, GW, KN, GC, and MH designed the study. CI, WB, AH, STM, RH-M, MT, GW, KN, and GC recruited and evaluated participants. TJS, AP-N, SKM, SCM, KH, MM, NB, ME, LJ, and RR collected and analysed laboratory data. AF-G, and BB accessed and verified the data. TJS, AF-G, AP-N, HM, BB, TS, RGW, and MH analysed data and interpreted results. KH, CH, and MK provided operational support. TJS, AF-G, HM, and MH drafted the Article. All authors had full access to the data, and reviewed, revised and gave final approval of the Article before submission.
The CORTIS-01 Study Team
Kesenogile Baepanye, Tshepiso Baepanye, Ken Clarke, Marelize Collignon, Audrey Dlamini, Candice Eyre, Tebogo Feni, Moogo Fikizolo, Phinda Galane, Thelma Goliath, Alia Gangat, Shirley Malefo-Grootboom, Elba Janse van Rensburg, Bonita Janse van Rensburg, Sophy Kekana, Marietjie Zietsman, Adrianne Kock, Israel Kunene, Aneessa Lakhi, Nondumiso Langa, Hilda Ledwaba, Marillyn Luphoko, Immaculate Mabasa, Dorah Mabe, Nkosinathi Mabuza, Molly Majola, Mantai Makhetha, Mpho Makoanyane, Blossom Makhubalo, Vernon Malay, Juanita Market, Selvy Matshego, Nontsikelelo Mbipa, Tsiamo Mmotsa, Sylvester Modipa, Samuel Mopati, Palesa Moswegu, Primrose Mothaga, Dorothy Muller, Grace Nchwe, Maryna Nel, Lindiwe Nhlangulela, Bantubonke Ntamo, Lawerence Ntoahae, Tedrius Ntshauba, Nomsa Sanyaka, Letlhogonolo Seabela, Pearl Selepe, Melissa Senne, MG Serake, Maria Thlapi, Vincent Tshikovhi, Lebogang Tswaile, Amanda van Aswegen, Lungile Mbata, Constance Takavamanya, Pedro Pinho, John Mdlulu, Marthinette Taljaard, Naydene Slabbert, Sharfuddin Sayed, Tanya Nielson, Melissa Senne, Ni Ni Sein, Lungile Mbata (The Aurum Institute); Dhineshree Govender, Tilagavathy Chinappa, Mbali Ignatia Zulu, Nonhle Bridgette Maphanga, Senzo Ralph Hlathi, Goodness Khanyisile Gumede, Thandiwe Yvonne Shezi, Jabulisiwe Lethabo Maphanga, Zandile Patrica Jali, Thobelani Cwele, Nonhlanhla Zanele Elsie Gwamanda, Celaphiwe Dlamini, Zibuyile Phindile Penlee Sing, Ntombozuko Gloria Ntanjana, Sphelele Simo Nzimande, Siyabonga Mbatha, Bhavna Maharaj, Atika Moosa, Cara-Mia Corris (Centre for the AIDS Programme of Research in South Africa); Fazlin Kafaar, Marwou De Kock, Hennie Geldenhuys, Angelique Kany Kany Luabeya, Justin Shenje, Natasja Botes, Susan Rossouw, Hadn Africa, Bongani Diamond, Samentra Braaf, Sonia Stryers, Alida Carstens, Ruwiyda Jansen, Simbarashe Mabwe, Roxane Herling, Ashley Veldsman, Lebohgang Makhete, Marcia Steyn, Sivuyile Buhlungu, Margareth Erasmus, Ilse Davids, Patiswa Plaatjie, Alessandro Companie, Frances Ratangee, Helen Veldtsman, Christel Petersen, Charmaine Abrahams, Miriam Moses, Xoliswa Kelepu, Yolande Gregg, Liticia Swanepoel, Nomsitho Magawu, Nompumelelo Cetywayo, Lauren Mactavie, Habibullah Valley, Elizabeth Filander, Nambitha Nqakala, Angelique Mouton, Fajwa Opperman, Elma Van Rooyen, Petrus Tyambetyu (South African Tuberculosis Vaccine Initiative, University of Cape Town); Elizna Maasdorp, Justine Khoury, Belinda Kriel, Bronwyn Smith, Liesel Muller, Susanne Tonsing, Andre Loxton, Andriette Hiemstra, Petri Ahlers, Marika Flinn (DST/NRF Centre of Excellence for Biomedical TB Research and SAMRC Centre for TB Research, Stellenbosch University); and Eva Chung, Michelle Chung, Alicia Sato (Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Research Center)
Declaration of interests
TJS has a patent of the RISK11 signature pending and reports grants from the Bill and Melinda Gates Foundation and South African Medical Research Council. KN reports grants from CAPRISA. GW reports a patent (PCT/IB2019/052043) pending to University of Cape Town, Stellenbosch University, Max-Planck-Gesellschaft Zur Foerderung Der Wissenschaften EV, Seattle Children's Hospital Doing Business as Seattle Children's Research Institute, and UK Research and Innovation. GC reports grants from the Bill & Melinda Gates Foundation. AP-N has a patent of the RISK11 signature pending and reports grants from the Bill & Melinda Gates Foundation and the South African Medical Research Council. MH reports grants from the Bill & Melinda Gates Foundation and the South African Medical Research Council. | ISONIAZID, PYRIDOXINE, RIFAPENTINE | DrugsGivenReaction | CC BY | 33508224 | 20,168,180 | 2021-03 |
What was the administration route of drug 'ISONIAZID'? | Biomarker-guided tuberculosis preventive therapy (CORTIS): a randomised controlled trial.
Targeted preventive therapy for individuals at highest risk of incident tuberculosis might impact the epidemic by interrupting transmission. We tested performance of a transcriptomic signature of tuberculosis (RISK11) and efficacy of signature-guided preventive therapy in parallel, using a hybrid three-group study design.
Adult volunteers aged 18-59 years were recruited at five geographically distinct communities in South Africa. Whole blood was sampled for RISK11 by quantitative RT-PCR assay from eligible volunteers without HIV, recent previous tuberculosis (ie, <3 years before screening), or comorbidities at screening. RISK11-positive participants were block randomised (1:2; block size 15) to once-weekly, directly-observed, open-label isoniazid and rifapentine for 12 weeks (ie, RISK11 positive and 3HP positive), or no treatment (ie, RISK11 positive and 3HP negative). A subset of eligible RISK11-negative volunteers were randomly assigned to no treatment (ie, RISK11 negative and 3HP negative). Diagnostic discrimination of prevalent tuberculosis was tested in all participants at baseline. Thereafter, prognostic discrimination of incident tuberculosis was tested in the untreated RISK11-positive versus RISK11-negative groups, and treatment efficacy in the 3HP-treated versus untreated RISK11-positive groups, during active surveillance through 15 months. The primary endpoint was microbiologically confirmed pulmonary tuberculosis. The primary outcome measures were risk ratio [RR] for tuberculosis of RISK11-positive to RISK11-negative participants, and treatment efficacy. This trial is registered with ClinicalTrials.gov, NCT02735590.
20 207 volunteers were screened, and 2923 participants were enrolled, including RISK11-positive participants randomly assigned to 3HP (n=375) or no 3HP (n=764), and 1784 RISK11-negative participants. Cumulative probability of prevalent or incident tuberculosis disease was 0·066 (95% CI 0·049 to 0·084) in RISK11-positive (3HP negative) participants and 0·018 (0·011 to 0·025) in RISK11-negative participants (RR 3·69, 95% CI 2·25-6·05) over 15 months. Tuberculosis prevalence was 47 (4·1%) of 1139 versus 14 (0·78%) of 1984 in RISK11-positive compared with RISK11-negative participants, respectively (diagnostic RR 5·13, 95% CI 2·93 to 9·43). Tuberculosis incidence over 15 months was 2·09 (95% CI 0·97 to 3·19) vs 0·80 (0·30 to 1·30) per 100 person years in RISK11-positive (3HP-negative) participants compared with RISK11-negative participants (cumulative incidence ratio 2·6, 95% CI 1·2 to 5·9). Serious adverse events related to 3HP included one hospitalisation for seizures (unintentional isoniazid overdose) and one death of unknown cause (possibly temporally related). Tuberculosis incidence over 15 months was 1·94 (95% CI 0·35 to 3·50) versus 2·09 (95% CI 0·97 to 3·19) per 100 person-years in 3HP-treated RISK11-positive participants compared with untreated RISK11-positive participants (efficacy 7·0%, 95% CI -145 to 65).
The RISK11 signature discriminated between individuals with prevalent tuberculosis, or progression to incident tuberculosis, and individuals who remained healthy, but provision of 3HP to signature-positive individuals after exclusion of baseline disease did not reduce progression to tuberculosis over 15 months.
Bill and Melinda Gates Foundation, South African Medical Research Council.
Introduction
Large-scale prevention of progression from Mycobacterium tuberculosis infection to tuberculosis disease is key to achieving WHO End TB Strategy targets, yet tuberculin skin tests (TST) and interferon (IFN) γ release assays have poor specificity for incident tuberculosis.1 A biomarker-targeted prevention strategy using a highly specific correlate of risk (COR) for incident tuberculosis, in tandem with effective short-course tuberculosis preventive therapy (TPT),2 might impact the epidemic by preventing incident tuberculosis disease before transmission.3 Modelling suggests a three-times reduction in burden of TPT if targeted by COR, compared with IFNγ release assays and TST.4 Furthermore, because active tuberculosis disease should be excluded before starting TPT, additional utility of the prognostic COR as a screening (triage) test to identify undiagnosed tuberculosis disease would allow earlier curative treatment. WHO and FIND have developed target product profiles (TPP) for triage tests for tuberculosis (optimal and minimum sensitivity of >95% and >90%, and specificity of >80% and >70%, respectively),5 and incipient tuberculosis tests (minimum sensitivity and specificity of 75% and 75%, and optimal sensitivity and specificity of 90% and 90%, respectively).6
Research in context
Evidence before this study
Host blood RNA signatures have potential as tuberculosis triage or diagnostic tests, and as predictive tests to target tuberculosis preventive therapy. We searched MEDLINE, Scopus, Web of Science, and EBSCO libraries for publications between Jan 1, 2005, and May 31, 2020, using the search terms “Tuberculosis” OR “TB” OR “Mycobacterium tuberculosis” OR “MTB” AND “diagnosis” OR “diagnostic” OR “detect” OR “predic”OR “prognosis” OR “prognostic” OR “screen” AND “Blood Biomarker” OR “blood biomarkers” OR “bio-signature” OR “gene expression” OR “genetic transcription” OR “host blood” OR “immune marker” OR “immunologic marker” OR “Ribonucleic Acid” OR “RNA” OR “signature” OR “surrogate endpoint” OR “surrogate marker” OR “transcriptome” OR “transcriptomic” AND “Area under curve” OR “AUC” OR “receiver operating characteristic” OR “ROC” OR “Accuracy” OR “Performance” OR “sensitivity” OR “specificity”. Studies comparing blood RNA signatures in individuals with tuberculosis versus Mycobacterium tuberculosis-uninfected controls, individuals with other respiratory diseases, or with M tuberculosis infection and using a microbiological reference standard of either sputum M tuberculosis culture, Xpert MTB/RIF, or smear microscopy for tuberculosis diagnosis, were included.
28 studies reported evaluation of 32 host blood RNA signatures for diagnosis or prediction of progression to tuberculosis disease in 83 cohorts. Only two studies prospectively tested performance of an RNA signature in all evaluable participants; the remainder used a case-control design. Multiple studies have tested tuberculosis preventive therapy in people with M tuberculosis latent tuberculosis infection. No studies have tested efficacy of tuberculosis preventive therapy to avert disease in RNA signature-positive people.
Added value of this study
This large randomised, controlled trial in five South African communities prospectively tested diagnostic and prognostic performance of an RNA signature (RISK11) in all evaluable participants, and estimated efficacy of tuberculosis preventive therapy to avert disease in RNA signature-positive people. More than 1% of HIV-uninfected community volunteers had previously undiagnosed, microbiologically confirmed tuberculosis at screening, more than 80% of which was asymptomatic. RISK11 showed moderate performance for tuberculosis triage, but good performance for diagnosis of symptomatic tuberculosis, and for short-term prediction of incident tuberculosis. 3 months of once-weekly, high-dose isoniazid and rifapentine (3HP) did not reduce incident disease in RISK11-positive individuals over 15 months of follow-up.
Implications of all the available evidence
Host blood biomarker development must consider that subclinical tuberculosis might be characterised by more heterogenous, or less pronounced blood inflammatory responses than symptomatic tuberculosis, or both, which will affect RNA signature performance. RISK11 might be better suited to screening of symptomatic individuals with possible tuberculosis than for mass community-based screening. RISK11 can identify those at highest risk for short-term progression to disease, but a more potent regimen than 3HP might be needed to prevent tuberculosis in RISK11-positive individuals.
We previously developed a 16-gene transcriptomic signature by whole blood RNA sequencing for identification of individuals at high risk of developing tuberculosis (the Zak16 signature).7, 8 Measurement of Zak16 was adapted to quantitative RT-PCR (RT-qPCR), and predictive ability for incident tuberculosis was validated in an independent longitudinal cohort of household contacts of tuberculosis patients.8 We reduced this signature to 11 genes (RISK11) with equivalent performance,9, 10 to allow testing in 96-well PCR format. Zak16 and RISK11 also did well as non-sputum screening tests for prevalent, active tuberculosis in case-control studies, measured by RNA sequencing, microarray,7, 8 or microfluidic RT-qPCR.9, 10 In a 2020 systematic review and patient-level pooled meta-analysis of 17 transcriptomic signatures for prognosis of incident tuberculosis, Zak16 was among eight signatures that achieved a positive predictive value above the WHO TPP benchmark for incipient tuberculosis tests.11 Since case-control studies might overestimate performance characteristics, testing in unselected populations is needed.
We report on a randomised controlled trial (CORTIS; NCT02735590), which prospectively measured diagnostic and prognostic performance of RISK11 for triage of prevalent and prediction of incident tuberculosis in South African adults; and, in parallel, estimated efficacy of short-course TPT to avert incident disease in RISK11-positive individuals.
Methods
Study design
This randomised controlled trial used a hybrid treatment selection, three-group study design to evaluate efficacy of the intervention and, in parallel, performance of the biomarker used to allocate that intervention (figure 1).2 The coprimary aims were to test, over 15 months, whether RISK11 status differentiates between people with and without cumulative prevalent or incident tuberculosis; and whether preventive therapy (weekly high-dose isoniazid and rifapentine for 12 weeks [3HP]) reduces tuberculosis incidence among RISK11-positive people compared with active surveillance only. RISK11 performance to detect prevalent tuberculosis was evaluated in all groups at baseline. RISK11 performance to predict incident tuberculosis was evaluated in the untreated RISK11-positive and RISK11-negative groups, and treatment efficacy was estimated from the 3HP treated and untreated RISK11-positive groups, after omitting participants with baseline tuberculosis. Efficiency of the hybrid study design was maximised by using the RISK11-positive and 3HP-negative group to evaluate both biomarker performance and treatment efficacy.Figure 1 Study design
The prevalence of RISK11 positivity was not precisely known in the study population; therefore, the number of individuals to be screened and the randomisation of RISK11-negative participants to enrolment was monitored and adjusted adaptively to ensure concurrent enrolment of the target number of RISK11-positive and RISK11-negative participants, per protocol specifications. The study used a three-group design to evaluate efficacy of the intervention and, in parallel, performance of the biomarker used to allocate that intervention. Diagnostic performance for differentiation of prevalent tuberculosis was tested in all three groups at baseline; prognostic performance for differentiation of incident tuberculosis over 15 months was tested in the two untreated groups (untreated RISK11 positive and untreated RISK11 negative); and treatment efficacy of 3HP over 15 months was tested in the two RISK11-positive groups (treated and untreated RISK11 positive). *Participants evaluated for eligibility at screening and enrolment. †Groups randomly assigned in blocks to ensure concurrent enrolment.
Routine implementation of TPT requires that patients are screened to exclude prevalent tuberculosis before TPT is provided to prevent incident disease. Therefore, because risk for prevalent and incident tuberculosis by RISK11 status must be understood before efficacy of preventive therapy against incident tuberculosis in RISK11-positive people can be interpreted, these secondary analyses are presented before the primary analysis of treatment efficacy.
The trial protocol (appendix p 21) was approved by the South African Health Products Regulatory Agency (20160305) by the Institutional Human Ethics Committees of participating sites; and was registered on ClinicalTrials.gov (NCT02735590). All participants provided written informed consent in their language of choice.
Participants
Adult volunteers living in tuberculosis-endemic communities in South Africa were recruited at five sites (South African Tuberculosis Vaccine Initiative, Worcester; Immunology Research Group, Stellenbosch University, Ravensmead; Aurum Institute, Klerksdorp and Rustenberg; and Centre for the AIDS Programme of Research in South Africa, Durban). Community-based recruitment was by word-of-mouth, house-to-house visits, and liaison with non-governmental organisations. Recruitment did not target groups at high risk of tuberculosis, such as household contacts. Eligible participants were aged between 18 years and 59 years, HIV-negative, without a history of tuberculosis disease in the last 3 years or preselected comorbidities (appendix p 8).
Screening
Venous blood was collected in PAXgene RNA tubes from all potentially eligible people at screening, frozen at −20°C, and shipped weekly to the South African Tuberculosis Vaccine Initiative Immunology Laboratory for RISK11 testing by qRT-PCR assay. Participants with a RISK11 score of at least 60% were classified a priori as RISK11 positive and less than 60% as RISK11 negative. This 60% threshold was the optimal point at which sensitivity and specificity for prognosis of incident tuberculosis were balanced in case-control studies.2 Samples with failed reference primer-probe reactions, with marked deviation in internal positive control sample from historical runs, or more than 30% failed interferon-stimulated genes primer-probe reactions (see quality control criteria and analysis script in Bitbucket instance) were classified as indeterminate. Per-participant qualitative results (RISK11 positive and RISK11 negative) were provided to the Triclinium Clinical Development (TCD) Data Centre for participant randomisation (see appendix pp 2–3).
Randomisation and masking
Assignment to study group was managed by an unmasked randomisation team from the TCD Data Centre, based on RISK11 status. RISK11-positive volunteers were randomly assigned (1:2; block size 15) to either open-label 3HP (3HP-positive group), or active tuberculosis surveillance without 3HP (3HP-negative group), in accordance with a randomisation schedule generated using SAS, version 9.4. RISK11-negative volunteers were concurrently randomly assigned either to active tuberculosis surveillance (3HP-negative group) or to non-participation, to enrich the study population for RISK11-positive participants.
Study group allocation was revealed to site staff after enrolment of eligible participants within 28 days of screening. The 3HP-negative group was double-blinded to RISK11 status, but unblinded to treatment allocation; the 3HP-positive group was unblinded to both RISK11-positive status and treatment allocation (figure 1). RISK11-positive participants randomly assigned to active surveillance did not receive a placebo, to maintain blinding of participants and study team members to RISK11 status.
Procedures
Target enrolment was maximally 3200 participants (1500 RISK11 positive and 1700 RISK11 negative). The randomisation ratio for RISK11-negative volunteers was adapted to ensure concurrent enrolment of the recruitment target. Adaptations occurred at intervals, informed by 3-monthly operational monitoring reports based on enrolment rate, RISK11-positive and RISK11-negative prevalence, and tuberculosis case accrual blinded to RISK11 status (appendix p 7).
Enrolment procedures included phlebotomy for IFNγ release assays (QuantiFERON TB Gold-Plus, Qiagen), tuberculosis symptom screen (a positive tuberculosis symptom screen included one or more symptoms of persistent unexplained cough, fever, night sweats, weight loss, or any haemoptysis), and collection of two spontaneous expectorated sputum samples for Xpert MTB/RIF assay (Cepheid) from all sputum-productive participants, regardless of symptoms.
All participants attended up to seven study visits, including four study site visits at months 3, 6, 12, and 15 (end of study), and three telephonic contact or field visits at months 1, 2, and 9. HIV testing was repeated at months 6 and 12.
Participants in the 3HP group received open-label, high-dose isoniazid (15 mg/kg; maximum dose 900 mg) with pyridoxine supplementation (25 mg) and rifapentine based on body weight (>32–50 kg, 750 mg; >50 kg, 900 mg), given weekly as directly observed oral doses, ideally with food, over 12 weeks. Completion of 3HP treatment was defined as receipt of 11 doses within 16 weeks (appendix p 3).
Outcomes
The two primary outcome measures were RISK11-positive to RISK11-negative risk ratio (RR) for prevalent or incident tuberculosis disease, and 3HP treatment efficacy through 15 months. Diagnostic performance for prevalent tuberculosis was evaluated on the presence of tuberculosis at the enrolment visit within the ITT cohort.
Participants in the 3HP group had each dose directly observed by study staff, and attended clinic for evaluation of solicited adverse events and possible adverse events of special interest at weeks 1–11. Solicited adverse events included gastrointestinal signs and symptoms suggestive of hepatotoxicity, such as nausea, vomiting, and jaundice. Possible hypersensitivity reactions, including influenza-like illness, were reported as adverse events of special interest. Safety events meeting the definition for a serious adverse event, whether deemed related or unrelated to study drug, were reported for both all participants through end of study.
Statistical analysis
The intention-to-treat (ITT) cohort included all enrolled participants who completed investigation for tuberculosis endpoints at baseline. The modified intention-to-treat (mITT) cohort included all participants in the ITT population who completed at least one post-baseline tuberculosis endpoint investigation and omitted participants with endpoint-defined tuberculosis disease at baseline (prevalent tuberculosis).
The diagnostic RR was estimated as a proportion of participants with tuberculosis disease among RISK11-positive divided by RISK11-negative participants. Prognostic performance for incident tuberculosis after enrolment was evaluated among 3HP-negative participants within the mITT cohort (ie, excluding participants with tuberculosis at baseline). Prognostic RR was estimated as the cumulative incidence through 15 months for RISK11-positive divided by RISK11-negative participants. The primary RR was an estimate of the probability of having prevalent tuberculosis or developing incident tuberculosis among RISK11-positive divided by RISK11-negative participants; this combined probability of prevalent and incident tuberculosis was computed for each group as the probability of prevalent tuberculosis plus the probability of incident tuberculosis through 15 months (conditioned on not having prevalent tuberculosis). Efficacy of 3HP preventive therapy to reduce the rate of incident tuberculosis disease compared with the untreated RISK11-positive participants was also evaluated in the mITT population. Treatment efficacy was estimated as one minus the cumulative incidence of RISK11-positive and 3HP-positive participants divided by RISK11-positive and 3HP-negative participants through 15 months. A per-protocol analysis of treatment efficacy was done and excluded RISK11-positive and 3HP-positive participants that received less than 11 of the 12 weekly doses of 3HP.
For statistical efficiency, a random subset of RISK11-negative participants were enrolled, therefore creating an ITT cohort artificially enriched with RISK11-positive participants. Therefore, unless stated otherwise, all analyses were adjusted so that results reflected the screened population. Secondary performance metrics such as sensitivity and specificity were estimated using standard formulas with binary endpoints; a percentile bootstrap with 20 000 samples was used to estimate 95% CIs. For descriptive analyses (Table 1, Table 2), rank-based Wilcoxon rank-sum tests were used to compare continuous variables in RISK11-positive versus RISK11-negative groups. Fisher's exact test was used to compare binary readouts; p values in Table 1, Table 2 were not adjusted for multiple comparisons. The prespecified statistical analysis plan is included in the appendix (p 82) and contains detailed description of the statistical methods.Table 1 Baseline characteristics and primary tuberculosis endpoints by group
Total (n=2923) RISK11 positive and 3HP positive (n=375) RISK11 positive and 3HP negative (n=764) RISK11 negative (n=1784) RISK11 positive vs RISK11 negative, p value*
Sex
Female 1585 (54·2%) 213 (56·8%) 469 (61·4%) 903 (50·6%) <0·001
Male 1338 (45·8%) 162 (43·2%) 295 (38·6%) 881 (49·4%) ..
Age, years 28·5 (9·0) 28·8 (9·5) 28·4 (9·2) 28·4 (8·7) 0·541
Race or ethnicity
Asian 4 (0·1%) 0 1 (0·1%) 3 (0·2%) 0·567
Black African 1947 (66·6%) 227 (60·5%) 477 (62·4%) 1243 (69·7%) <0·001
White 4 (0·1%) 0 1 (0·1%) 3 (0·2%) 0·567
Mixed race 968 (33·1%) 148 (39·5%) 285 (37·3%) 535 (30·0%) <0·001
Body-mass index, kg/m2 24·6 (7·7) 24·1 (6·3) 24·4 (6·1) 24·9 (8·6) 0·354
Previous tuberculosis 230 (7·9%) 36 (9·6%) 75 (9·8%) 119 (6·7%) 0·003
Smoking 1478 (50·6%) 203 (54·1%) 391 (51·2%) 884 (49·6%) 0·170
Family tuberculosis history 462 (15·8%) 66 (17·6%) 110 (14·4%) 286 (16·0%) 0·675
Interferon γ release assay positive 1895 (64·8%) 250 (66·7%) 528 (69·1%) 1117 (62·6%) <0·001
Follow-up, months 15 (9·4–15·0) 15 (11·1–15·0) 15 (9·1–15·0) 13·6 (9·4–15·0) 0·056
Prevalent tuberculosis, n (probability, 95% CI) 61 (1·1%, 0·77–1·6)† 47 (4·1%, 3·1–5·4)‡ 47 (4·1%, 3·1–5·4)§ 14 (0·78%, 0·47–1·3) NA
Incident tuberculosis, n (cases per 100 person years, 95% CI) 24 (1·05, 0·59–1·5)§ 6 (1·9, 0·35–3·5) 14 (2·09, 0·97–3·19) 10 (0·80, 0·30–1·30) NA
Cumulative tuberculosis, n (probability, 95% CI)¶ 85 (0·022, 0·016–0·028)† 61 (0·066, 0·049–0·084)‖** 61 (0·066, 0·049–0·084)** 24 (0·018, 0·011–0·026) NA
Data are n (%), mean (SD), or median (IQR), unless stated otherwise. Secondary tuberculosis endpoints by group are in the appendix (p 13). NA=not applicable.
* For continuous data, p values from Wilcoxon rank sum test. For categorical data, p values from Fischer's exact test.
† Overall rate estimates are weighted combinations of the enrolled participants to reflect the screened population.
‡ Overall incidence and cumulative tuberculosis excludes RISK11-positive and 3HP-positive incident cases.
§ Prevalent tuberculosis among RISK11 positive was assessed by combining the 3HP-negative and 3HP-positive groups. Value is repeated for RISK11 positive and 3HP positive, and RISK11 positive and 3HP negative.
¶ Probability of observing prevalent or incident tuberculosis over 15 months.
‖ Probability of prevalent or incident tuberculosis not estimated for RISK11-positive and 3HP-positive because it would combine data from before and after 3HP treatment and is therefore potentially misleading.
** Estimate for RISK11 positive includes 3HP-positive prevalent cases and 3HP-negative prevalent and incident cases. Value is repeated for RISK11 positive and 3HP positive, and RISK11 positive and 3HP negative.
Table 2 Performance of RISK11 and IGRA for prevalent and incident tuberculosis
Prevalent tuberculosis (ITT cohort) Incident tuberculosis (mITT cohort)*
RISK11 (60)† RISK11 (26)† IGRA RISK11 (60)† RISK11 (26)† IGRA
Risk ratio 5·13 (2·93 to 9·43) 7·39 (3·46 to 25·69) 4·43 (1·93 to 14·18) 2·61 (1·15 to 5·94) 2·67 (1·04 to 8·66) 2·83 (0·95 to 99·79)
Biomarker prevalence 9·2% (9·2 to 9·2) 25·8% (24·1 to 27·4) 63·4% (61·3 to 65·4) 9·0% (9·0 to 9·0) 25·3% (23·7 to 26·9) 63·2% (61·1 to 65·3)
AUC‡ 0·77 (0·68 to 0·86) .. 0·66 (0·58 to 0·73) 0·63 (0·47 to 0·80) .. 0·67 (0·54 to 0·79)
Sensitivity 34·9% (23·7 to 52·2) 72·1% (54·5 to 90·2) 88·7% (77·1 to 96·4) 25·0% (12·7 to 45·9) 47·5% (25·9 to 75·0) 83·2% (61·9 to 100·0)
Specificity 91·0% (90·9 to 91·1) 74·7% (73·1 to 76·4) 36·9% (34·9 to 39·0) 91·1% (91·0 to 91·2) 74·9% (73·2 to 76·5) 37·0% (34·9 to 39·1)
PPV§ 4·1% (3·0 to 5·4) 3·1% (2·0 to 4·3) 1·5% (1·0 to 2·2) 1·9% (0·9 to 3·0) 1·3% (0·6 to 2·1) 0·9% (0·5 to 1·4)
PPV (2% incidence)¶ .. .. .. 6·7% (3·5 to 11·8) 4·6% (2·5 to 7·1) 3·3% (2·5 to 3·9)
NPV§ 99·2% (98·8 to 99·6) 99·6% (99·2 to 99·9) 99·7% (99·3 to 99·9) 99·4% (99·0 to 99·8) 99·5% (99·1 to 99·9) 99·7% (99·2 to 100·0)
NPV (2% incidence)¶ .. .. .. 97·9% (97·6 to 98·5) 98·2% (97·5 to 99·2) 98·8% (97·4 to 100·0)
NNS or NNT‖ 29·9 (21·8 to 46·6) 37·8 (25·5 to 65·7) 83·1 (53·2 to 179·8) 75·1 (40·4 to 277·5) 123·8 (47·2 to 834·1) 168 (−440 to 1059)
Data are risk ratio (95 %CI), % (95% CI), AUC (95% CI), or NNS or NNT (95% CI). ITT=intention to treat. mITT=modified intention-to-treat. IGRA=interferon γ release assay. AUC=area under the receiver operating characteristic curve. PPV=positive predictive value. NPV=negative predictive value. NNS=number needed to screen. NNT=number needed to treat.
* Computed over 15-month prognostic window. Performance of RISK11 and IGRA for incident tuberculosis over 6-month and 12-month prognostic windows is in the appendix (p 16).
† RISK11 score threshold at 60% or 26%.
‡ AUC is computed across all score thresholds and value is presented under RISK11 (60).
§ Computed using the prevalence and incidence rates in the trial population as appropriate.
¶ Computed assuming 2% annual incidence of tuberculosis in the population.
‖ NNS for prevalent tuberculosis; NNT for incident tuberculosis. Performance of RISK11 and IGRA for prevalent and incident tuberculosis based on secondary endpoint (≥1 sample+) is in the appendix (p 15).
The study was designed to have 90% power to reject the null hypothesis of a RISK11-positive and RISK11-negative cumulative risk ratio less than 2 with one-sided alpha of 0·025. For treatment efficacy there was 80% power to reject the null hypothesis of efficacy less than 20%, with one-sided alpha of 0·05 and under the alternative design hypothesis that efficacy was 80%. To compute statistical power for these aims, a stochastic simulation of the trial was constructed, based on which we expected to observe 33 tuberculosis disease endpoints among 1500 RISK11-positive participants and seven tuberculosis disease endpoints among 1700 RISK11-negative participants (appendix p 6).
Role of the funding source
The trial was funded by the Bill & Melinda Gates Foundation (OPP1116632, OPP1137034) and the Strategic Health Innovation Partnerships Unit of the South African Medical Research Council, with funds received from the South African Department of Science and Technology. The Gates Foundation contributed to the study design. The regulatory sponsor was the University of Cape Town. Rifapentine (PRIFTIN) was donated by the manufacturer (Sanofi), who had no role in the design, implementation, analysis, or reporting of the trial. All authors had access to all the data reported in the study. The corresponding author had final responsibility for the decision to submit for publication.
Results
Between Sept 20, 2016, and Oct 19, 2018, 20 207 volunteers consented to participation; 16 248 met inclusion criteria at screening and 15 777 with a RISK11 result were potentially eligible for enrolment (figure 2). Of the 20 207 adults assessed for eligibility, common reasons for exclusion included HIV infection (1246 [6·1%]) and comorbid conditions (1369 [6·8%]; appendix p 8). 2923 eligible participants were enrolled after randomisation (1784 [61·0%] RISK11 negative and 1139 [39·0%] RISK11 positive; table 1).Figure 2 Trial profile
ITT=intention to treat. mITT=modified intention to treat. LTFU=lost to follow-up. PP=per protocol analysis. *585 participants did not complete the trial for reasons including: 53 (9%) pregnancies, 22 (4%) investigator withdrawals, 46 (8%) consent withdrawals, 26 (4%) HIV infections, 422 (72%) LTFU, and 16 (3%) deaths.
Participants were enrolled at five geographically diverse sites across South Africa (appendix pp 9–11). Among participants with a RISK11 result, 1434 (9·3%) of 15 494 were RISK11 positive, with the proportion ranging from 6·2% to 13·0% across the five sites. RISK11-positive participants were randomly asigned either to receive treatment (375 [32·9%] RISK11 positive and 3HP positive) or undergo observation without treatment (764 [67·1%] RISK11 positive and 3HP negative).
There were no significant differences in smoking history, family history of tuberculosis, or febrile illness between RISK11-positive and RISK11-negative participants (table 1). A higher proportion of RISK11-positive (75 [9·8%] of 364) than RISK11-negative (119 [6·7%] of 1784) participants reported previous tuberculosis disease (p=0·003). Compared with RISK11 negative participants, a greater proportion of RISK11-positive participants were female and mixed race (p<0·001; table 1).
Median duration of follow-up for incident tuberculosis was 13·9 months (IQR 9·0–15·0) and 1879 (66%) of 2500 3HP-negative mITT participants attended at least six scheduled visits. 1416 (49%) of 2838 participants were followed up for 15 months and 2160 (75%) of 2838 participants were followed up for at least 9 months. 585 (21%) of 2838 participants did not complete the study because of withdrawal, death, or loss to follow-up (figure 2; table 1).
Among 91 participants with tuberculosis who reached the primary endpoint, 61 were diagnosed with prevalent tuberculosis at baseline (47 RISK11 positive and 14 RISK11 negative; table 1; appendix p 13). Prevalence of tuberculosis in RISK11-positive and RISK11-negative participants was 4·1% (95% CI 3·1–5·4) and 0·78% (0·5–1·3), respectively (figure 3). Thereafter, 24 participants in the untreated group were diagnosed with incident tuberculosis disease (14 RISK11 positive and ten RISK11 negative; table 1; appendix p 13) with overall incidence of 1·05 cases (95% CI 0·59–1·5) per 100 person-years.Figure 3 RISK11 detection of combined prevalent and incident tuberculosis and diagnostic performance
(A) Prevalence of tuberculosis in RISK11-positive (47 cases,) and RISK11-negative (14 cases, red bar) participants at trial enrolment. Error bars depict 95% CI. Cumulative incidence probability of tuberculosis in RISK11-positive (14 cases, blue line) or RISK11-negative (10 cases, red line) mITT participants during follow-up. Shaded areas represent 95% CI. (B) Ratio of RISK11-positive versus RISK11 negative cumulative incidence probability of observing prevalent or incident tuberculosis disease, in the ITT population of the observation group. (C) RISK11 signature scores (each dot represents a participant) measured at screening in trial participants, stratified on tuberculosis diagnosis. Boxes depict IQR, midline represents the median, and whiskers indicate range among enrolled participants. (D) RISK11 signature scores measured at screening in prevalent tuberculosis cases with or without any tuberculosis symptoms, in incident tuberculosis cases or those who did not have a tuberculosis diagnosis. The enrolled population, not the screened population, is represented in (C) and (D), because a large fraction of RISK11-negative participants were not enrolled by design. (E) ROC curves depicting RISK11 diagnostic performance for prevalent tuberculosis in the ITT population, for prevalent tuberculosis among individuals with no symptoms of tuberculosis (asymptomatic) and among individuals with at least one symptom consistent with tuberculosis disease (symptomatic). Shaded areas represent the 95% CI. The grey and black dots indicate the minimum and optimal criteria, respectively, set out in the WHO target product profile for a triage test. The empty dot indicates the criteria set out in the WHO target product profile for a confirmatory diagnostic test. TRP=true positive rate. ITT=intention to treat. FPR=false positive rate. AUC=area under the receiver operating characteristic curve.
In the primary analysis of biomarker performance for cumulative tuberculosis, cumulative probability of observing prevalent or incident tuberculosis disease in the ITT population was 0·066 (95% CI 0·049–0·084) in RISK11-positive participants and 0·018 (0·011–0·025) in RISK11-negative participants, with a risk ratio of 3·69 (95% CI 2·25–6·05) over 15 months (figure 3).
A wide range of RISK11 scores was observed, irrespective of tuberculosis outcome (figure 3). Among enrolled participants, those who remained tuberculosis free (controls) had significantly lower RISK11 scores (24·2%, IQR 8·2–75·3) than those with prevalent or incident tuberculosis disease (76·7%, 36·6–94·4; Wilcoxon rank-sum test p<0·0001; figure 3).
In the secondary analysis of biomarker performance for prevalent tuberculosis, using the prespecified RISK11 test threshold (60%) there was 5·13-times (95% CI 3·01–10·69) increased risk of prevalent tuberculosis disease at baseline in RISK11-positive versus RISK11-negative participants, with sensitivity of 35% (95% CI 24–52) and specificity of 91% (95% CI 91–91; table 2). The receiver operating characteristic (ROC) analysis (figure 3) showed that a RISK11 threshold of 26% provided sensitivity of 72% (95% CI 54–90) and specificity of 75% (95% CI 73–76; table 2); with area under the diagnostic ROC curve (AUC) of 0·77 (95% CI 0·68–0·86). These performance estimates did not meet the minimum criteria for a tuberculosis triage test (table 2). 50 (83·6%) of 61 participants with prevalent tuberculosis had no symptoms compatible with tuberculosis disease, and the remaining 11 participants with at least one symptom consistent with tuberculosis had RISK11 scores of more than 80% (median 96%; figure 3; appendix p 14). Discrimination between symptomatic prevalent tuberculosis and symptomatic controls was high (AUC 0·97, 95% CI 0·95–0·99; figure 3) and, with a highly specific threshold, performance exceeded the optimal TPP for a tuberculosis triage test in this population. By contrast, RISK11 discriminated between asymptomatic controls and asymptomatic prevalent tuberculosis cases with an AUC of 0·75 (95% CI 0·66–0·84; figure 3).
In the secondary analysis of biomarker performance for incident tuberculosis, annualised incidence was 2·1 versus 0·8 per 100 person-years among the RISK11-positive versus RISK11-negative participants, respectively, which was equivalent to a 0·026 (95% CI 0·01–0·04) versus 0·010 (0·004–0·02) cumulative incident probability of developing tuberculosis disease over 15 months, respectively (figure 3). No incident tuberculosis cases were detected in RISK11-negative participants until 8·7 months (figure 3). Tuberculosis incidence through 15 months among RISK11-positive participants was 2·61 (95% CI 1·15–5·94) times higher than RISK11-negative participants (table 2); and the RISK11 signature discriminated between incident tuberculosis cases and controls with AUC of 0·63 (95% CI 0·47–0·80; figure 4). Over this period, at the predefined 60% threshold, RISK11 showed very low sensitivity of 25% (95% CI 12–46) with specificity of 91% (95% CI 91–91). At an exploratory RISK11 threshold of 26%, which provided 75% specificity, sensitivity was 47% (95% CI 26–74). By comparison, the prognostic sensitivity of IFNγ release assays over 15 months was 83% (62–100), but more than 60% of the population was IFNγ release assay positive (specificity 37%, 95% CI 35–40; table 2).Figure 4 Prognostic performance of RISK11 and treatment efficacy of 3HP
(A) ROC curve depicting RISK11 prognostic performance for incident tuberculosis through 15 months of follow-up. The shaded area represents 95% CI. The grey and black dots depict the minimum and optimal criteria, respectively, set out in the WHO target product profile for an incipient tuberculosis test. (B) RISK11 performance (area under the ROC curve) for endpoints within a 6-month sliding window from month 0 through 15. The shaded area represents 95% CI. (C) ROC curves depicting RISK11 prognostic performance for incident tuberculosis through expanding follow-up periods. The grey and black dots depict the minimum and optimal criteria, respectively, set out in the WHO target product profile for an incipient tuberculosis test. (D) Cumulative incidence of tuberculosis in RISK11-positive participants who were randomly assigned to 3HP (six cases, red line) and RISK11-positive participants who were randomly assigned to observation (14 cases, blue line) during follow-up. The shaded areas represent 95% CI. (E) Cumulative incidence of tuberculosis in participants who met criteria for treatment adherence per protocol, stratified into RISK11-positive participants who were randomly assigned to 3HP (four cases, red line) and RISK11-positive participants who were randomly assigned to observation (14 cases, blue line) during follow-up. (F) TE estimated through follow-up in participants who met criteria for treatment adherence per protocol. The shaded areas represent 95% CI. TRP=true positive rate. FPR=false positive rate. AUC=area under the receiver operating characteristic curve. TPP=target product profile. TE=treatment efficacy.
RISK11 prognostic performance was highly dependent on time to disease. Instantaneous RISK11 performance, estimated from 6-month sliding windows, showed prognostic discrimination was high (AUC >0·80) for approximately 9 months, before waning towards 0·58 between months 9 and 15 (figure 4; appendix p 16). Prognostic performance of RISK11 for incident tuberculosis within 6 months (AUC 0·95, 95% CI 0·92–1·0) exceeded the optimal TPP for an incipient tuberculosis test (appendix p 16), and for tuberculosis disease within 12 months (0·80, 0·65–0·94; figure 4) approached the minimum TPP (appendix p 16), but over a 15-month period did not meet minimum criteria for a prognostic tuberculosis test (table 2).
In the primary analysis of treatment efficacy among RISK11-positive participants, tuberculosis incidence in the 3HP-positive and 3HP-negative groups was 1·94 cases per 100 person years and 2·09 cases per 100 person years, respectively (figure 4; table 1), with estimated treatment efficacy of 7·0% (95% CI −145 to 64·7) over 15 months. In the subgroup of 286 adherent participants who completed at least 11 doses within 16 weeks, efficacy was 22% (−138 to 74; figure 4) over 15 months. Notably, among adherent participants, there were no tuberculosis cases through 9 months (figure 4).
Adverse events related to 3HP were mostly of mild to moderate severity (appendix p 12). 67 serious adverse events, including 29 due to trauma, occurred in 65 participants. Serious adverse events occurred in 20 (5·3%) of 375 RISK11-positive participants who received 3HP (eight serious adverse events due to trauma), compared with 12 (1·6%) of 764 in RISK11-positive and 3HP-negative participants (Fisher's exact p<0·001). Among RISK11-negative participants, 33 (1·9%) of 1784 experienced serious adverse events. All but two serious adverse events were deemed unrelated to 3HP. Serious adverse events related to 3HP included one hospitalisation for seizures (unintentional isoniazid overdose) and one death of unknown cause (possibly temporally related). One death of unknown cause also occurred in an untreated RISK11-negative participant. There were 16 deaths in total, including five RISK11-positive participants receiving 3HP (three deaths due to trauma), three untreated RISK11-positive participants, and eight RISK11-negative participants.
3HP was halted in 28 (7·5%) of 375 participants, due to an adverse event of special interest (influenza-like illness or other possible hypersensitivity reaction) in 17 (4·5%), hepatotoxicity in one (0·3%), gastrointestinal symptoms in three (0·8%), and seizures in three (0·8%) participants.
RISK11 diagnostic and prognostic performance and treatment efficacy of 3HP based on the secondary endpoint definition (at least one sputum sample; appendix p 14) are described in the appendix (p 15).
Five (8·2%) of the 61 participants witih prevalent tuberculosis were resistant to isoniazid or rifampicin, or both. Two (6·7%) of the 30 participants with incident tuberculosis, both in the untreated group, were resistant to isoniazid and rifampicin. No participants were observed to have drug-resistant incident tuberculosis in the 3HP-positive group.
Discussion
Our goal was to evaluate a biomarker-targeted, community-based strategy to detect missing tuberculosis cases among people who do not seek health care, whose disease might not be detected by symptom-focused screening algorithms, and to prevent disease among those at highest risk of progression to tuberculosis. The RISK11 assay was an effective screening test for active disease in symptomatic participants, in whom performance exceeded the requirements for a triage test, but less so in asymptomatic participants. The RISK11 signature was able to predict risk for tuberculosis disease progression, in a trial population with tuberculosis incidence exceeding one case per 100 person-years, but optimal prognostic performance was limited to a 6-month horizon. While risk-targeted 3HP did not prevent tuberculosis disease over 15 months, there was some evidence of transient efficacy through 9 months among fully adherent participants.
Community-based recruitment of ambulant volunteers was not focused on individuals with known risk factors for tuberculosis, such as household contact. Individuals with recent previous history of tuberculosis (>3 years before screening) and HIV infection were excluded. Nevertheless, more than 1% of study volunteers had previously undiagnosed, microbiologically confirmed tuberculosis at enrolment, based on spontaneous expectorated rather than induced sputum samples. More than 80% of these baseline tuberculosis cases did not have any symptom compatible with tuberculosis disease and would not have been detected by a tuberculosis screening strategy that requires symptoms as the entry point to investigation. This finding is consistent with 46–79% prevalence (median 50%) of subclinical tuberculosis reported in prevalence surveys.12, 13, 14 It is not known whether subclinical tuberculosis would have progressed to symptomatic disease, spontaneously halted, or even reversed if left untreated,15, 16 nor whether subclinical disease directly contributes to M tuberculosis transmission.17 Further research is needed to determine the importance of detection, treatment, and prevention of subclinical disease for global tuberculosis control.
Although very few prevalent tuberculosis cases were symptomatic, RISK11 performance for discrimination of symptomatic prevalent tuberculosis cases from symptomatic controls exceeded the optimal TPP criteria for a triage test, while not meeting the stringent criteria for a confirmatory diagnostic test.5 A 2020 prospective observational study among symptomatic individuals who self-presented to a tuberculosis clinic assessed diagnostic accuracy of 27 transcriptomic signatures for discrimination between prevalent tuberculosis cases and controls.18 The 16-gene Zak signature, from which RISK11 was derived, did not meet the minimum WHO criteria for a triage test, but four of the 27 signatures met these criteria, suggesting that another signature might perform as well as or better than RISK11. RISK11 discrimination of asymptomatic prevalent tuberculosis cases from asymptomatic controls was modest and did not meet the minimal criteria for a triage test. These findings suggest that host blood biomarker development must consider that subclinical tuberculosis might be characterised by more heterogenous or less pronounced peripheral blood inflammatory responses than symptomatic tuberculosis, or both, which affects RNA signature performance. This finding is consistent with lower inflammatory profiles, observed by blood transcriptomic and proteomic analyses, during the subclinical phases of tuberculosis progression compared with subsequent symptomatic, active disease.19, 20 The modest performance characteristics for asymptomatic prevalent tuberculosis would limit applicability of RISK11 for biomarker-targeted, mass community screening in the South African setting, where the majority of baseline tuberculosis cases were subclinical. A host blood biomarker with good sensitivity and specificity for symptomatic tuberculosis might be most useful in countries with low to medium tuberculosis burden, where individuals with compatible symptoms might not otherwise be investigated for tuberculosis. Future diagnostic studies in symptomatic patients seeking health care should also include patients with extrapulmonary and culture-negative tuberculosis, particularly in HIV-infected cohorts, and the full spectrum of differential diagnoses that commonly mimic tuberculosis.
Prognostic performance of RISK11 for risk of progression to incident tuberculosis was poor through 15 months and did not meet the minimum TPP criteria for an incipient tuberculosis test through this prognostic horizon.4 However, good prognostic performance was observed for incident tuberculosis within 12 months of testing and performance exceeded the optimal TPP criteria for tuberculosis occurring within 6 months of testing. The positive predictive value for incident disease (1·9 vs 0·9 for RISK11 compared with IFNγ release assay, respectively) was computed from the observed tuberculosis incidence rate, which was lower than that typically used in estimations (2%).3, 6 It is not possible to determine whether the late incident tuberculosis cases occurring among RISK11-negative participants were due to reactivation or new M tuberculosis infection. We infer that a prognostic test with optimal short-term performance might be useful in identifying people who would benefit from an efficacious intervention in a low-incidence setting, in which the timing of M tuberculosis exposure is often known and subsequent exposure is unlikely.
The 3HP regimen was previously shown to be as effective as 9 months of isoniazid in preventing tuberculosis among individuals with known exposure or positive TST.21 Ethical equipoise of the intervention and control groups in this trial was based on the fact that RISK11 had been validated in selected case-control studies, which can overestimate biomarker performance, and thus risk for tuberculosis among RISK11-positive individuals needed to be tested prospectively in the field. Furthermore, although TPT is given commonly to IFNγ release assay-positive and tuberculin skin test-positive individuals, and individuals with known household exposure to a tuberculosis patient, the vast majority do not progress to tuberculosis disease if left untreated. The risk–benefit balance of 3HP preventive therapy for RISK11-positive individuals was unknown. However, we found no evidence that 3HP treatment reduced the rate of incident tuberculosis over 15 months in RISK11-positive individuals, who might be further advanced along the spectrum of tuberculosis pathogenesis.19 Interpretation of the results is limited by the wide CIs. It is also notable that no tuberculosis cases were observed in fully adherent participants through 9 months. This finding is consistent with the possibility that 3HP was sufficient to temporarily halt, but insufficient to sterilise, incipient tuberculosis, resulting in reactivation. A RISK11-targeted preventive therapy strategy for high tuberculosis transmission settings like South Africa might require a more potent therapeutic regimen than 3HP. 3HP might have been sufficient to sterilise incipient tuberculosis disease, but not to protect against tuberculosis disease resulting from reinfection after completion of the treatment course. Although it is not possible to distinguish between reactivation and reinfection tuberculosis cases in this study, we suggest that the limited time available for reinfection and subsequent progression to disease after completing 3HP makes the latter possibility less likely.
The study was subject to a number of limitations. The hybrid design required an open-label treatment group,2 with no placebo for RISK11-positive participants, so that risk for tuberculosis could also be evaluated in the control group while concealing RISK11 status from participants, site staff, and tuberculosis endpoint laboratory staff for analysis of biomarker performance. Tuberculosis case accrual during the latter stages of follow-up suggested no evidence of ascertainment bias during treatment. Extensive study simulations were done to inform the size of each group for the coprimary analyses. However, due to lower than expected prevalence of RISK11-positive status in the screened population (9·3% vs 15%), enrolment of 1139 RISK11-positive individuals required 2 years, compared with planned enrolment of 1500 RISK11-positive individuals over 1 year. As a result, fewer than expected incident tuberculosis outcomes were observed (24 vs 40 primary endpoints), which might have reduced power for both treatment efficacy and RISK11 performance analyses. Not all participants in the treatment group completed 3HP per protocol, because study drug was discontinued for suspected hypersensitivity reactions or influenza-like illnesses. However, the discontinuation rate (7·5%) was comparable to other trials of 3HP, in which study drug was discontinued in 17·9% of participants overall and in 4·9% due to an adverse event.21 The loss to follow-up rate in this trial (14·4%) was higher than expected and might reflect the challenges of retaining the study participants, in the absence of traditional tuberculosis risk factors for which surveillance is routine. However, loss to follow-up occurred predominantly after the treatment period and did not seem to have been biased by treatment factors. We note that median duration of participation was 13·9 months and thus loss to follow-up did not have major unforeseen effect on statistical power. Strengths of the study include enrolment in geographically distinct sites across South Africa that were representative of populations with different rates of IFNγ release assay positivity and tuberculosis disease, which were congruent with local rates of RISK11 positivity, although the sample size was not sufficient for analysis of signature performance or 3HP efficacy at site level. The findings broadly reflect the South African tuberculosis epidemic, but might not be directly applicable to countries with much lower tuberculosis incidence.
It is not yet known whether other parsimonious tuberculosis signatures, developed and validated like RISK11 in carefully curated case-control studies, will exhibit similar performance characteristics when prospectively tested in the field, where undiagnosed subclinical tuberculosis might pose a challenge to diagnostic performance. Head-to-head analyses of several transcriptomic tuberculosis signatures with promising diagnostic performance are currently underway on CORTIS samples and novel near-patient testing platforms are in development, which might bring cost-effective, community-based tuberculosis biomarker screening closer to implementation in the field. However, although we have shown that a strategy of biomarker-guided tuberculosis preventive therapy is feasible, the optimal preventive therapy regimen for use in such a strategy remains elusive.
Data sharing
Deidentified RISK11 signature scores and primary tuberculosis endpoint data from all participants will be available with publication. The dataset is deposited in Zivahub (https://doi.org/10.25375/uct.13573337.v1), an open access data repository hosted by the University of Cape Town's institutional data repository powered by Figshare for Institutions.
Supplementary Material
Supplementary appendix
Acknowledgments
The trial was funded by the Bill & Melinda Gates Foundation (OPP1116632, OPP1137034) and the Strategic Health Innovation Partnerships Unit of the South African Medical Research Council with funds received from the South African Department of Science and Technology. Rifapentine was donated by the manufacturer (Sanofi). The authors thank the members of the data and safety monitoring board and the trial steering committee.
Contributors
TJS, AF-G, AP-N, SS, GW, KN, GC, and MH designed the study. CI, WB, AH, STM, RH-M, MT, GW, KN, and GC recruited and evaluated participants. TJS, AP-N, SKM, SCM, KH, MM, NB, ME, LJ, and RR collected and analysed laboratory data. AF-G, and BB accessed and verified the data. TJS, AF-G, AP-N, HM, BB, TS, RGW, and MH analysed data and interpreted results. KH, CH, and MK provided operational support. TJS, AF-G, HM, and MH drafted the Article. All authors had full access to the data, and reviewed, revised and gave final approval of the Article before submission.
The CORTIS-01 Study Team
Kesenogile Baepanye, Tshepiso Baepanye, Ken Clarke, Marelize Collignon, Audrey Dlamini, Candice Eyre, Tebogo Feni, Moogo Fikizolo, Phinda Galane, Thelma Goliath, Alia Gangat, Shirley Malefo-Grootboom, Elba Janse van Rensburg, Bonita Janse van Rensburg, Sophy Kekana, Marietjie Zietsman, Adrianne Kock, Israel Kunene, Aneessa Lakhi, Nondumiso Langa, Hilda Ledwaba, Marillyn Luphoko, Immaculate Mabasa, Dorah Mabe, Nkosinathi Mabuza, Molly Majola, Mantai Makhetha, Mpho Makoanyane, Blossom Makhubalo, Vernon Malay, Juanita Market, Selvy Matshego, Nontsikelelo Mbipa, Tsiamo Mmotsa, Sylvester Modipa, Samuel Mopati, Palesa Moswegu, Primrose Mothaga, Dorothy Muller, Grace Nchwe, Maryna Nel, Lindiwe Nhlangulela, Bantubonke Ntamo, Lawerence Ntoahae, Tedrius Ntshauba, Nomsa Sanyaka, Letlhogonolo Seabela, Pearl Selepe, Melissa Senne, MG Serake, Maria Thlapi, Vincent Tshikovhi, Lebogang Tswaile, Amanda van Aswegen, Lungile Mbata, Constance Takavamanya, Pedro Pinho, John Mdlulu, Marthinette Taljaard, Naydene Slabbert, Sharfuddin Sayed, Tanya Nielson, Melissa Senne, Ni Ni Sein, Lungile Mbata (The Aurum Institute); Dhineshree Govender, Tilagavathy Chinappa, Mbali Ignatia Zulu, Nonhle Bridgette Maphanga, Senzo Ralph Hlathi, Goodness Khanyisile Gumede, Thandiwe Yvonne Shezi, Jabulisiwe Lethabo Maphanga, Zandile Patrica Jali, Thobelani Cwele, Nonhlanhla Zanele Elsie Gwamanda, Celaphiwe Dlamini, Zibuyile Phindile Penlee Sing, Ntombozuko Gloria Ntanjana, Sphelele Simo Nzimande, Siyabonga Mbatha, Bhavna Maharaj, Atika Moosa, Cara-Mia Corris (Centre for the AIDS Programme of Research in South Africa); Fazlin Kafaar, Marwou De Kock, Hennie Geldenhuys, Angelique Kany Kany Luabeya, Justin Shenje, Natasja Botes, Susan Rossouw, Hadn Africa, Bongani Diamond, Samentra Braaf, Sonia Stryers, Alida Carstens, Ruwiyda Jansen, Simbarashe Mabwe, Roxane Herling, Ashley Veldsman, Lebohgang Makhete, Marcia Steyn, Sivuyile Buhlungu, Margareth Erasmus, Ilse Davids, Patiswa Plaatjie, Alessandro Companie, Frances Ratangee, Helen Veldtsman, Christel Petersen, Charmaine Abrahams, Miriam Moses, Xoliswa Kelepu, Yolande Gregg, Liticia Swanepoel, Nomsitho Magawu, Nompumelelo Cetywayo, Lauren Mactavie, Habibullah Valley, Elizabeth Filander, Nambitha Nqakala, Angelique Mouton, Fajwa Opperman, Elma Van Rooyen, Petrus Tyambetyu (South African Tuberculosis Vaccine Initiative, University of Cape Town); Elizna Maasdorp, Justine Khoury, Belinda Kriel, Bronwyn Smith, Liesel Muller, Susanne Tonsing, Andre Loxton, Andriette Hiemstra, Petri Ahlers, Marika Flinn (DST/NRF Centre of Excellence for Biomedical TB Research and SAMRC Centre for TB Research, Stellenbosch University); and Eva Chung, Michelle Chung, Alicia Sato (Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Research Center)
Declaration of interests
TJS has a patent of the RISK11 signature pending and reports grants from the Bill and Melinda Gates Foundation and South African Medical Research Council. KN reports grants from CAPRISA. GW reports a patent (PCT/IB2019/052043) pending to University of Cape Town, Stellenbosch University, Max-Planck-Gesellschaft Zur Foerderung Der Wissenschaften EV, Seattle Children's Hospital Doing Business as Seattle Children's Research Institute, and UK Research and Innovation. GC reports grants from the Bill & Melinda Gates Foundation. AP-N has a patent of the RISK11 signature pending and reports grants from the Bill & Melinda Gates Foundation and the South African Medical Research Council. MH reports grants from the Bill & Melinda Gates Foundation and the South African Medical Research Council. | Oral | DrugAdministrationRoute | CC BY | 33508224 | 20,168,180 | 2021-03 |
What was the administration route of drug 'PYRIDOXINE'? | Biomarker-guided tuberculosis preventive therapy (CORTIS): a randomised controlled trial.
Targeted preventive therapy for individuals at highest risk of incident tuberculosis might impact the epidemic by interrupting transmission. We tested performance of a transcriptomic signature of tuberculosis (RISK11) and efficacy of signature-guided preventive therapy in parallel, using a hybrid three-group study design.
Adult volunteers aged 18-59 years were recruited at five geographically distinct communities in South Africa. Whole blood was sampled for RISK11 by quantitative RT-PCR assay from eligible volunteers without HIV, recent previous tuberculosis (ie, <3 years before screening), or comorbidities at screening. RISK11-positive participants were block randomised (1:2; block size 15) to once-weekly, directly-observed, open-label isoniazid and rifapentine for 12 weeks (ie, RISK11 positive and 3HP positive), or no treatment (ie, RISK11 positive and 3HP negative). A subset of eligible RISK11-negative volunteers were randomly assigned to no treatment (ie, RISK11 negative and 3HP negative). Diagnostic discrimination of prevalent tuberculosis was tested in all participants at baseline. Thereafter, prognostic discrimination of incident tuberculosis was tested in the untreated RISK11-positive versus RISK11-negative groups, and treatment efficacy in the 3HP-treated versus untreated RISK11-positive groups, during active surveillance through 15 months. The primary endpoint was microbiologically confirmed pulmonary tuberculosis. The primary outcome measures were risk ratio [RR] for tuberculosis of RISK11-positive to RISK11-negative participants, and treatment efficacy. This trial is registered with ClinicalTrials.gov, NCT02735590.
20 207 volunteers were screened, and 2923 participants were enrolled, including RISK11-positive participants randomly assigned to 3HP (n=375) or no 3HP (n=764), and 1784 RISK11-negative participants. Cumulative probability of prevalent or incident tuberculosis disease was 0·066 (95% CI 0·049 to 0·084) in RISK11-positive (3HP negative) participants and 0·018 (0·011 to 0·025) in RISK11-negative participants (RR 3·69, 95% CI 2·25-6·05) over 15 months. Tuberculosis prevalence was 47 (4·1%) of 1139 versus 14 (0·78%) of 1984 in RISK11-positive compared with RISK11-negative participants, respectively (diagnostic RR 5·13, 95% CI 2·93 to 9·43). Tuberculosis incidence over 15 months was 2·09 (95% CI 0·97 to 3·19) vs 0·80 (0·30 to 1·30) per 100 person years in RISK11-positive (3HP-negative) participants compared with RISK11-negative participants (cumulative incidence ratio 2·6, 95% CI 1·2 to 5·9). Serious adverse events related to 3HP included one hospitalisation for seizures (unintentional isoniazid overdose) and one death of unknown cause (possibly temporally related). Tuberculosis incidence over 15 months was 1·94 (95% CI 0·35 to 3·50) versus 2·09 (95% CI 0·97 to 3·19) per 100 person-years in 3HP-treated RISK11-positive participants compared with untreated RISK11-positive participants (efficacy 7·0%, 95% CI -145 to 65).
The RISK11 signature discriminated between individuals with prevalent tuberculosis, or progression to incident tuberculosis, and individuals who remained healthy, but provision of 3HP to signature-positive individuals after exclusion of baseline disease did not reduce progression to tuberculosis over 15 months.
Bill and Melinda Gates Foundation, South African Medical Research Council.
Introduction
Large-scale prevention of progression from Mycobacterium tuberculosis infection to tuberculosis disease is key to achieving WHO End TB Strategy targets, yet tuberculin skin tests (TST) and interferon (IFN) γ release assays have poor specificity for incident tuberculosis.1 A biomarker-targeted prevention strategy using a highly specific correlate of risk (COR) for incident tuberculosis, in tandem with effective short-course tuberculosis preventive therapy (TPT),2 might impact the epidemic by preventing incident tuberculosis disease before transmission.3 Modelling suggests a three-times reduction in burden of TPT if targeted by COR, compared with IFNγ release assays and TST.4 Furthermore, because active tuberculosis disease should be excluded before starting TPT, additional utility of the prognostic COR as a screening (triage) test to identify undiagnosed tuberculosis disease would allow earlier curative treatment. WHO and FIND have developed target product profiles (TPP) for triage tests for tuberculosis (optimal and minimum sensitivity of >95% and >90%, and specificity of >80% and >70%, respectively),5 and incipient tuberculosis tests (minimum sensitivity and specificity of 75% and 75%, and optimal sensitivity and specificity of 90% and 90%, respectively).6
Research in context
Evidence before this study
Host blood RNA signatures have potential as tuberculosis triage or diagnostic tests, and as predictive tests to target tuberculosis preventive therapy. We searched MEDLINE, Scopus, Web of Science, and EBSCO libraries for publications between Jan 1, 2005, and May 31, 2020, using the search terms “Tuberculosis” OR “TB” OR “Mycobacterium tuberculosis” OR “MTB” AND “diagnosis” OR “diagnostic” OR “detect” OR “predic”OR “prognosis” OR “prognostic” OR “screen” AND “Blood Biomarker” OR “blood biomarkers” OR “bio-signature” OR “gene expression” OR “genetic transcription” OR “host blood” OR “immune marker” OR “immunologic marker” OR “Ribonucleic Acid” OR “RNA” OR “signature” OR “surrogate endpoint” OR “surrogate marker” OR “transcriptome” OR “transcriptomic” AND “Area under curve” OR “AUC” OR “receiver operating characteristic” OR “ROC” OR “Accuracy” OR “Performance” OR “sensitivity” OR “specificity”. Studies comparing blood RNA signatures in individuals with tuberculosis versus Mycobacterium tuberculosis-uninfected controls, individuals with other respiratory diseases, or with M tuberculosis infection and using a microbiological reference standard of either sputum M tuberculosis culture, Xpert MTB/RIF, or smear microscopy for tuberculosis diagnosis, were included.
28 studies reported evaluation of 32 host blood RNA signatures for diagnosis or prediction of progression to tuberculosis disease in 83 cohorts. Only two studies prospectively tested performance of an RNA signature in all evaluable participants; the remainder used a case-control design. Multiple studies have tested tuberculosis preventive therapy in people with M tuberculosis latent tuberculosis infection. No studies have tested efficacy of tuberculosis preventive therapy to avert disease in RNA signature-positive people.
Added value of this study
This large randomised, controlled trial in five South African communities prospectively tested diagnostic and prognostic performance of an RNA signature (RISK11) in all evaluable participants, and estimated efficacy of tuberculosis preventive therapy to avert disease in RNA signature-positive people. More than 1% of HIV-uninfected community volunteers had previously undiagnosed, microbiologically confirmed tuberculosis at screening, more than 80% of which was asymptomatic. RISK11 showed moderate performance for tuberculosis triage, but good performance for diagnosis of symptomatic tuberculosis, and for short-term prediction of incident tuberculosis. 3 months of once-weekly, high-dose isoniazid and rifapentine (3HP) did not reduce incident disease in RISK11-positive individuals over 15 months of follow-up.
Implications of all the available evidence
Host blood biomarker development must consider that subclinical tuberculosis might be characterised by more heterogenous, or less pronounced blood inflammatory responses than symptomatic tuberculosis, or both, which will affect RNA signature performance. RISK11 might be better suited to screening of symptomatic individuals with possible tuberculosis than for mass community-based screening. RISK11 can identify those at highest risk for short-term progression to disease, but a more potent regimen than 3HP might be needed to prevent tuberculosis in RISK11-positive individuals.
We previously developed a 16-gene transcriptomic signature by whole blood RNA sequencing for identification of individuals at high risk of developing tuberculosis (the Zak16 signature).7, 8 Measurement of Zak16 was adapted to quantitative RT-PCR (RT-qPCR), and predictive ability for incident tuberculosis was validated in an independent longitudinal cohort of household contacts of tuberculosis patients.8 We reduced this signature to 11 genes (RISK11) with equivalent performance,9, 10 to allow testing in 96-well PCR format. Zak16 and RISK11 also did well as non-sputum screening tests for prevalent, active tuberculosis in case-control studies, measured by RNA sequencing, microarray,7, 8 or microfluidic RT-qPCR.9, 10 In a 2020 systematic review and patient-level pooled meta-analysis of 17 transcriptomic signatures for prognosis of incident tuberculosis, Zak16 was among eight signatures that achieved a positive predictive value above the WHO TPP benchmark for incipient tuberculosis tests.11 Since case-control studies might overestimate performance characteristics, testing in unselected populations is needed.
We report on a randomised controlled trial (CORTIS; NCT02735590), which prospectively measured diagnostic and prognostic performance of RISK11 for triage of prevalent and prediction of incident tuberculosis in South African adults; and, in parallel, estimated efficacy of short-course TPT to avert incident disease in RISK11-positive individuals.
Methods
Study design
This randomised controlled trial used a hybrid treatment selection, three-group study design to evaluate efficacy of the intervention and, in parallel, performance of the biomarker used to allocate that intervention (figure 1).2 The coprimary aims were to test, over 15 months, whether RISK11 status differentiates between people with and without cumulative prevalent or incident tuberculosis; and whether preventive therapy (weekly high-dose isoniazid and rifapentine for 12 weeks [3HP]) reduces tuberculosis incidence among RISK11-positive people compared with active surveillance only. RISK11 performance to detect prevalent tuberculosis was evaluated in all groups at baseline. RISK11 performance to predict incident tuberculosis was evaluated in the untreated RISK11-positive and RISK11-negative groups, and treatment efficacy was estimated from the 3HP treated and untreated RISK11-positive groups, after omitting participants with baseline tuberculosis. Efficiency of the hybrid study design was maximised by using the RISK11-positive and 3HP-negative group to evaluate both biomarker performance and treatment efficacy.Figure 1 Study design
The prevalence of RISK11 positivity was not precisely known in the study population; therefore, the number of individuals to be screened and the randomisation of RISK11-negative participants to enrolment was monitored and adjusted adaptively to ensure concurrent enrolment of the target number of RISK11-positive and RISK11-negative participants, per protocol specifications. The study used a three-group design to evaluate efficacy of the intervention and, in parallel, performance of the biomarker used to allocate that intervention. Diagnostic performance for differentiation of prevalent tuberculosis was tested in all three groups at baseline; prognostic performance for differentiation of incident tuberculosis over 15 months was tested in the two untreated groups (untreated RISK11 positive and untreated RISK11 negative); and treatment efficacy of 3HP over 15 months was tested in the two RISK11-positive groups (treated and untreated RISK11 positive). *Participants evaluated for eligibility at screening and enrolment. †Groups randomly assigned in blocks to ensure concurrent enrolment.
Routine implementation of TPT requires that patients are screened to exclude prevalent tuberculosis before TPT is provided to prevent incident disease. Therefore, because risk for prevalent and incident tuberculosis by RISK11 status must be understood before efficacy of preventive therapy against incident tuberculosis in RISK11-positive people can be interpreted, these secondary analyses are presented before the primary analysis of treatment efficacy.
The trial protocol (appendix p 21) was approved by the South African Health Products Regulatory Agency (20160305) by the Institutional Human Ethics Committees of participating sites; and was registered on ClinicalTrials.gov (NCT02735590). All participants provided written informed consent in their language of choice.
Participants
Adult volunteers living in tuberculosis-endemic communities in South Africa were recruited at five sites (South African Tuberculosis Vaccine Initiative, Worcester; Immunology Research Group, Stellenbosch University, Ravensmead; Aurum Institute, Klerksdorp and Rustenberg; and Centre for the AIDS Programme of Research in South Africa, Durban). Community-based recruitment was by word-of-mouth, house-to-house visits, and liaison with non-governmental organisations. Recruitment did not target groups at high risk of tuberculosis, such as household contacts. Eligible participants were aged between 18 years and 59 years, HIV-negative, without a history of tuberculosis disease in the last 3 years or preselected comorbidities (appendix p 8).
Screening
Venous blood was collected in PAXgene RNA tubes from all potentially eligible people at screening, frozen at −20°C, and shipped weekly to the South African Tuberculosis Vaccine Initiative Immunology Laboratory for RISK11 testing by qRT-PCR assay. Participants with a RISK11 score of at least 60% were classified a priori as RISK11 positive and less than 60% as RISK11 negative. This 60% threshold was the optimal point at which sensitivity and specificity for prognosis of incident tuberculosis were balanced in case-control studies.2 Samples with failed reference primer-probe reactions, with marked deviation in internal positive control sample from historical runs, or more than 30% failed interferon-stimulated genes primer-probe reactions (see quality control criteria and analysis script in Bitbucket instance) were classified as indeterminate. Per-participant qualitative results (RISK11 positive and RISK11 negative) were provided to the Triclinium Clinical Development (TCD) Data Centre for participant randomisation (see appendix pp 2–3).
Randomisation and masking
Assignment to study group was managed by an unmasked randomisation team from the TCD Data Centre, based on RISK11 status. RISK11-positive volunteers were randomly assigned (1:2; block size 15) to either open-label 3HP (3HP-positive group), or active tuberculosis surveillance without 3HP (3HP-negative group), in accordance with a randomisation schedule generated using SAS, version 9.4. RISK11-negative volunteers were concurrently randomly assigned either to active tuberculosis surveillance (3HP-negative group) or to non-participation, to enrich the study population for RISK11-positive participants.
Study group allocation was revealed to site staff after enrolment of eligible participants within 28 days of screening. The 3HP-negative group was double-blinded to RISK11 status, but unblinded to treatment allocation; the 3HP-positive group was unblinded to both RISK11-positive status and treatment allocation (figure 1). RISK11-positive participants randomly assigned to active surveillance did not receive a placebo, to maintain blinding of participants and study team members to RISK11 status.
Procedures
Target enrolment was maximally 3200 participants (1500 RISK11 positive and 1700 RISK11 negative). The randomisation ratio for RISK11-negative volunteers was adapted to ensure concurrent enrolment of the recruitment target. Adaptations occurred at intervals, informed by 3-monthly operational monitoring reports based on enrolment rate, RISK11-positive and RISK11-negative prevalence, and tuberculosis case accrual blinded to RISK11 status (appendix p 7).
Enrolment procedures included phlebotomy for IFNγ release assays (QuantiFERON TB Gold-Plus, Qiagen), tuberculosis symptom screen (a positive tuberculosis symptom screen included one or more symptoms of persistent unexplained cough, fever, night sweats, weight loss, or any haemoptysis), and collection of two spontaneous expectorated sputum samples for Xpert MTB/RIF assay (Cepheid) from all sputum-productive participants, regardless of symptoms.
All participants attended up to seven study visits, including four study site visits at months 3, 6, 12, and 15 (end of study), and three telephonic contact or field visits at months 1, 2, and 9. HIV testing was repeated at months 6 and 12.
Participants in the 3HP group received open-label, high-dose isoniazid (15 mg/kg; maximum dose 900 mg) with pyridoxine supplementation (25 mg) and rifapentine based on body weight (>32–50 kg, 750 mg; >50 kg, 900 mg), given weekly as directly observed oral doses, ideally with food, over 12 weeks. Completion of 3HP treatment was defined as receipt of 11 doses within 16 weeks (appendix p 3).
Outcomes
The two primary outcome measures were RISK11-positive to RISK11-negative risk ratio (RR) for prevalent or incident tuberculosis disease, and 3HP treatment efficacy through 15 months. Diagnostic performance for prevalent tuberculosis was evaluated on the presence of tuberculosis at the enrolment visit within the ITT cohort.
Participants in the 3HP group had each dose directly observed by study staff, and attended clinic for evaluation of solicited adverse events and possible adverse events of special interest at weeks 1–11. Solicited adverse events included gastrointestinal signs and symptoms suggestive of hepatotoxicity, such as nausea, vomiting, and jaundice. Possible hypersensitivity reactions, including influenza-like illness, were reported as adverse events of special interest. Safety events meeting the definition for a serious adverse event, whether deemed related or unrelated to study drug, were reported for both all participants through end of study.
Statistical analysis
The intention-to-treat (ITT) cohort included all enrolled participants who completed investigation for tuberculosis endpoints at baseline. The modified intention-to-treat (mITT) cohort included all participants in the ITT population who completed at least one post-baseline tuberculosis endpoint investigation and omitted participants with endpoint-defined tuberculosis disease at baseline (prevalent tuberculosis).
The diagnostic RR was estimated as a proportion of participants with tuberculosis disease among RISK11-positive divided by RISK11-negative participants. Prognostic performance for incident tuberculosis after enrolment was evaluated among 3HP-negative participants within the mITT cohort (ie, excluding participants with tuberculosis at baseline). Prognostic RR was estimated as the cumulative incidence through 15 months for RISK11-positive divided by RISK11-negative participants. The primary RR was an estimate of the probability of having prevalent tuberculosis or developing incident tuberculosis among RISK11-positive divided by RISK11-negative participants; this combined probability of prevalent and incident tuberculosis was computed for each group as the probability of prevalent tuberculosis plus the probability of incident tuberculosis through 15 months (conditioned on not having prevalent tuberculosis). Efficacy of 3HP preventive therapy to reduce the rate of incident tuberculosis disease compared with the untreated RISK11-positive participants was also evaluated in the mITT population. Treatment efficacy was estimated as one minus the cumulative incidence of RISK11-positive and 3HP-positive participants divided by RISK11-positive and 3HP-negative participants through 15 months. A per-protocol analysis of treatment efficacy was done and excluded RISK11-positive and 3HP-positive participants that received less than 11 of the 12 weekly doses of 3HP.
For statistical efficiency, a random subset of RISK11-negative participants were enrolled, therefore creating an ITT cohort artificially enriched with RISK11-positive participants. Therefore, unless stated otherwise, all analyses were adjusted so that results reflected the screened population. Secondary performance metrics such as sensitivity and specificity were estimated using standard formulas with binary endpoints; a percentile bootstrap with 20 000 samples was used to estimate 95% CIs. For descriptive analyses (Table 1, Table 2), rank-based Wilcoxon rank-sum tests were used to compare continuous variables in RISK11-positive versus RISK11-negative groups. Fisher's exact test was used to compare binary readouts; p values in Table 1, Table 2 were not adjusted for multiple comparisons. The prespecified statistical analysis plan is included in the appendix (p 82) and contains detailed description of the statistical methods.Table 1 Baseline characteristics and primary tuberculosis endpoints by group
Total (n=2923) RISK11 positive and 3HP positive (n=375) RISK11 positive and 3HP negative (n=764) RISK11 negative (n=1784) RISK11 positive vs RISK11 negative, p value*
Sex
Female 1585 (54·2%) 213 (56·8%) 469 (61·4%) 903 (50·6%) <0·001
Male 1338 (45·8%) 162 (43·2%) 295 (38·6%) 881 (49·4%) ..
Age, years 28·5 (9·0) 28·8 (9·5) 28·4 (9·2) 28·4 (8·7) 0·541
Race or ethnicity
Asian 4 (0·1%) 0 1 (0·1%) 3 (0·2%) 0·567
Black African 1947 (66·6%) 227 (60·5%) 477 (62·4%) 1243 (69·7%) <0·001
White 4 (0·1%) 0 1 (0·1%) 3 (0·2%) 0·567
Mixed race 968 (33·1%) 148 (39·5%) 285 (37·3%) 535 (30·0%) <0·001
Body-mass index, kg/m2 24·6 (7·7) 24·1 (6·3) 24·4 (6·1) 24·9 (8·6) 0·354
Previous tuberculosis 230 (7·9%) 36 (9·6%) 75 (9·8%) 119 (6·7%) 0·003
Smoking 1478 (50·6%) 203 (54·1%) 391 (51·2%) 884 (49·6%) 0·170
Family tuberculosis history 462 (15·8%) 66 (17·6%) 110 (14·4%) 286 (16·0%) 0·675
Interferon γ release assay positive 1895 (64·8%) 250 (66·7%) 528 (69·1%) 1117 (62·6%) <0·001
Follow-up, months 15 (9·4–15·0) 15 (11·1–15·0) 15 (9·1–15·0) 13·6 (9·4–15·0) 0·056
Prevalent tuberculosis, n (probability, 95% CI) 61 (1·1%, 0·77–1·6)† 47 (4·1%, 3·1–5·4)‡ 47 (4·1%, 3·1–5·4)§ 14 (0·78%, 0·47–1·3) NA
Incident tuberculosis, n (cases per 100 person years, 95% CI) 24 (1·05, 0·59–1·5)§ 6 (1·9, 0·35–3·5) 14 (2·09, 0·97–3·19) 10 (0·80, 0·30–1·30) NA
Cumulative tuberculosis, n (probability, 95% CI)¶ 85 (0·022, 0·016–0·028)† 61 (0·066, 0·049–0·084)‖** 61 (0·066, 0·049–0·084)** 24 (0·018, 0·011–0·026) NA
Data are n (%), mean (SD), or median (IQR), unless stated otherwise. Secondary tuberculosis endpoints by group are in the appendix (p 13). NA=not applicable.
* For continuous data, p values from Wilcoxon rank sum test. For categorical data, p values from Fischer's exact test.
† Overall rate estimates are weighted combinations of the enrolled participants to reflect the screened population.
‡ Overall incidence and cumulative tuberculosis excludes RISK11-positive and 3HP-positive incident cases.
§ Prevalent tuberculosis among RISK11 positive was assessed by combining the 3HP-negative and 3HP-positive groups. Value is repeated for RISK11 positive and 3HP positive, and RISK11 positive and 3HP negative.
¶ Probability of observing prevalent or incident tuberculosis over 15 months.
‖ Probability of prevalent or incident tuberculosis not estimated for RISK11-positive and 3HP-positive because it would combine data from before and after 3HP treatment and is therefore potentially misleading.
** Estimate for RISK11 positive includes 3HP-positive prevalent cases and 3HP-negative prevalent and incident cases. Value is repeated for RISK11 positive and 3HP positive, and RISK11 positive and 3HP negative.
Table 2 Performance of RISK11 and IGRA for prevalent and incident tuberculosis
Prevalent tuberculosis (ITT cohort) Incident tuberculosis (mITT cohort)*
RISK11 (60)† RISK11 (26)† IGRA RISK11 (60)† RISK11 (26)† IGRA
Risk ratio 5·13 (2·93 to 9·43) 7·39 (3·46 to 25·69) 4·43 (1·93 to 14·18) 2·61 (1·15 to 5·94) 2·67 (1·04 to 8·66) 2·83 (0·95 to 99·79)
Biomarker prevalence 9·2% (9·2 to 9·2) 25·8% (24·1 to 27·4) 63·4% (61·3 to 65·4) 9·0% (9·0 to 9·0) 25·3% (23·7 to 26·9) 63·2% (61·1 to 65·3)
AUC‡ 0·77 (0·68 to 0·86) .. 0·66 (0·58 to 0·73) 0·63 (0·47 to 0·80) .. 0·67 (0·54 to 0·79)
Sensitivity 34·9% (23·7 to 52·2) 72·1% (54·5 to 90·2) 88·7% (77·1 to 96·4) 25·0% (12·7 to 45·9) 47·5% (25·9 to 75·0) 83·2% (61·9 to 100·0)
Specificity 91·0% (90·9 to 91·1) 74·7% (73·1 to 76·4) 36·9% (34·9 to 39·0) 91·1% (91·0 to 91·2) 74·9% (73·2 to 76·5) 37·0% (34·9 to 39·1)
PPV§ 4·1% (3·0 to 5·4) 3·1% (2·0 to 4·3) 1·5% (1·0 to 2·2) 1·9% (0·9 to 3·0) 1·3% (0·6 to 2·1) 0·9% (0·5 to 1·4)
PPV (2% incidence)¶ .. .. .. 6·7% (3·5 to 11·8) 4·6% (2·5 to 7·1) 3·3% (2·5 to 3·9)
NPV§ 99·2% (98·8 to 99·6) 99·6% (99·2 to 99·9) 99·7% (99·3 to 99·9) 99·4% (99·0 to 99·8) 99·5% (99·1 to 99·9) 99·7% (99·2 to 100·0)
NPV (2% incidence)¶ .. .. .. 97·9% (97·6 to 98·5) 98·2% (97·5 to 99·2) 98·8% (97·4 to 100·0)
NNS or NNT‖ 29·9 (21·8 to 46·6) 37·8 (25·5 to 65·7) 83·1 (53·2 to 179·8) 75·1 (40·4 to 277·5) 123·8 (47·2 to 834·1) 168 (−440 to 1059)
Data are risk ratio (95 %CI), % (95% CI), AUC (95% CI), or NNS or NNT (95% CI). ITT=intention to treat. mITT=modified intention-to-treat. IGRA=interferon γ release assay. AUC=area under the receiver operating characteristic curve. PPV=positive predictive value. NPV=negative predictive value. NNS=number needed to screen. NNT=number needed to treat.
* Computed over 15-month prognostic window. Performance of RISK11 and IGRA for incident tuberculosis over 6-month and 12-month prognostic windows is in the appendix (p 16).
† RISK11 score threshold at 60% or 26%.
‡ AUC is computed across all score thresholds and value is presented under RISK11 (60).
§ Computed using the prevalence and incidence rates in the trial population as appropriate.
¶ Computed assuming 2% annual incidence of tuberculosis in the population.
‖ NNS for prevalent tuberculosis; NNT for incident tuberculosis. Performance of RISK11 and IGRA for prevalent and incident tuberculosis based on secondary endpoint (≥1 sample+) is in the appendix (p 15).
The study was designed to have 90% power to reject the null hypothesis of a RISK11-positive and RISK11-negative cumulative risk ratio less than 2 with one-sided alpha of 0·025. For treatment efficacy there was 80% power to reject the null hypothesis of efficacy less than 20%, with one-sided alpha of 0·05 and under the alternative design hypothesis that efficacy was 80%. To compute statistical power for these aims, a stochastic simulation of the trial was constructed, based on which we expected to observe 33 tuberculosis disease endpoints among 1500 RISK11-positive participants and seven tuberculosis disease endpoints among 1700 RISK11-negative participants (appendix p 6).
Role of the funding source
The trial was funded by the Bill & Melinda Gates Foundation (OPP1116632, OPP1137034) and the Strategic Health Innovation Partnerships Unit of the South African Medical Research Council, with funds received from the South African Department of Science and Technology. The Gates Foundation contributed to the study design. The regulatory sponsor was the University of Cape Town. Rifapentine (PRIFTIN) was donated by the manufacturer (Sanofi), who had no role in the design, implementation, analysis, or reporting of the trial. All authors had access to all the data reported in the study. The corresponding author had final responsibility for the decision to submit for publication.
Results
Between Sept 20, 2016, and Oct 19, 2018, 20 207 volunteers consented to participation; 16 248 met inclusion criteria at screening and 15 777 with a RISK11 result were potentially eligible for enrolment (figure 2). Of the 20 207 adults assessed for eligibility, common reasons for exclusion included HIV infection (1246 [6·1%]) and comorbid conditions (1369 [6·8%]; appendix p 8). 2923 eligible participants were enrolled after randomisation (1784 [61·0%] RISK11 negative and 1139 [39·0%] RISK11 positive; table 1).Figure 2 Trial profile
ITT=intention to treat. mITT=modified intention to treat. LTFU=lost to follow-up. PP=per protocol analysis. *585 participants did not complete the trial for reasons including: 53 (9%) pregnancies, 22 (4%) investigator withdrawals, 46 (8%) consent withdrawals, 26 (4%) HIV infections, 422 (72%) LTFU, and 16 (3%) deaths.
Participants were enrolled at five geographically diverse sites across South Africa (appendix pp 9–11). Among participants with a RISK11 result, 1434 (9·3%) of 15 494 were RISK11 positive, with the proportion ranging from 6·2% to 13·0% across the five sites. RISK11-positive participants were randomly asigned either to receive treatment (375 [32·9%] RISK11 positive and 3HP positive) or undergo observation without treatment (764 [67·1%] RISK11 positive and 3HP negative).
There were no significant differences in smoking history, family history of tuberculosis, or febrile illness between RISK11-positive and RISK11-negative participants (table 1). A higher proportion of RISK11-positive (75 [9·8%] of 364) than RISK11-negative (119 [6·7%] of 1784) participants reported previous tuberculosis disease (p=0·003). Compared with RISK11 negative participants, a greater proportion of RISK11-positive participants were female and mixed race (p<0·001; table 1).
Median duration of follow-up for incident tuberculosis was 13·9 months (IQR 9·0–15·0) and 1879 (66%) of 2500 3HP-negative mITT participants attended at least six scheduled visits. 1416 (49%) of 2838 participants were followed up for 15 months and 2160 (75%) of 2838 participants were followed up for at least 9 months. 585 (21%) of 2838 participants did not complete the study because of withdrawal, death, or loss to follow-up (figure 2; table 1).
Among 91 participants with tuberculosis who reached the primary endpoint, 61 were diagnosed with prevalent tuberculosis at baseline (47 RISK11 positive and 14 RISK11 negative; table 1; appendix p 13). Prevalence of tuberculosis in RISK11-positive and RISK11-negative participants was 4·1% (95% CI 3·1–5·4) and 0·78% (0·5–1·3), respectively (figure 3). Thereafter, 24 participants in the untreated group were diagnosed with incident tuberculosis disease (14 RISK11 positive and ten RISK11 negative; table 1; appendix p 13) with overall incidence of 1·05 cases (95% CI 0·59–1·5) per 100 person-years.Figure 3 RISK11 detection of combined prevalent and incident tuberculosis and diagnostic performance
(A) Prevalence of tuberculosis in RISK11-positive (47 cases,) and RISK11-negative (14 cases, red bar) participants at trial enrolment. Error bars depict 95% CI. Cumulative incidence probability of tuberculosis in RISK11-positive (14 cases, blue line) or RISK11-negative (10 cases, red line) mITT participants during follow-up. Shaded areas represent 95% CI. (B) Ratio of RISK11-positive versus RISK11 negative cumulative incidence probability of observing prevalent or incident tuberculosis disease, in the ITT population of the observation group. (C) RISK11 signature scores (each dot represents a participant) measured at screening in trial participants, stratified on tuberculosis diagnosis. Boxes depict IQR, midline represents the median, and whiskers indicate range among enrolled participants. (D) RISK11 signature scores measured at screening in prevalent tuberculosis cases with or without any tuberculosis symptoms, in incident tuberculosis cases or those who did not have a tuberculosis diagnosis. The enrolled population, not the screened population, is represented in (C) and (D), because a large fraction of RISK11-negative participants were not enrolled by design. (E) ROC curves depicting RISK11 diagnostic performance for prevalent tuberculosis in the ITT population, for prevalent tuberculosis among individuals with no symptoms of tuberculosis (asymptomatic) and among individuals with at least one symptom consistent with tuberculosis disease (symptomatic). Shaded areas represent the 95% CI. The grey and black dots indicate the minimum and optimal criteria, respectively, set out in the WHO target product profile for a triage test. The empty dot indicates the criteria set out in the WHO target product profile for a confirmatory diagnostic test. TRP=true positive rate. ITT=intention to treat. FPR=false positive rate. AUC=area under the receiver operating characteristic curve.
In the primary analysis of biomarker performance for cumulative tuberculosis, cumulative probability of observing prevalent or incident tuberculosis disease in the ITT population was 0·066 (95% CI 0·049–0·084) in RISK11-positive participants and 0·018 (0·011–0·025) in RISK11-negative participants, with a risk ratio of 3·69 (95% CI 2·25–6·05) over 15 months (figure 3).
A wide range of RISK11 scores was observed, irrespective of tuberculosis outcome (figure 3). Among enrolled participants, those who remained tuberculosis free (controls) had significantly lower RISK11 scores (24·2%, IQR 8·2–75·3) than those with prevalent or incident tuberculosis disease (76·7%, 36·6–94·4; Wilcoxon rank-sum test p<0·0001; figure 3).
In the secondary analysis of biomarker performance for prevalent tuberculosis, using the prespecified RISK11 test threshold (60%) there was 5·13-times (95% CI 3·01–10·69) increased risk of prevalent tuberculosis disease at baseline in RISK11-positive versus RISK11-negative participants, with sensitivity of 35% (95% CI 24–52) and specificity of 91% (95% CI 91–91; table 2). The receiver operating characteristic (ROC) analysis (figure 3) showed that a RISK11 threshold of 26% provided sensitivity of 72% (95% CI 54–90) and specificity of 75% (95% CI 73–76; table 2); with area under the diagnostic ROC curve (AUC) of 0·77 (95% CI 0·68–0·86). These performance estimates did not meet the minimum criteria for a tuberculosis triage test (table 2). 50 (83·6%) of 61 participants with prevalent tuberculosis had no symptoms compatible with tuberculosis disease, and the remaining 11 participants with at least one symptom consistent with tuberculosis had RISK11 scores of more than 80% (median 96%; figure 3; appendix p 14). Discrimination between symptomatic prevalent tuberculosis and symptomatic controls was high (AUC 0·97, 95% CI 0·95–0·99; figure 3) and, with a highly specific threshold, performance exceeded the optimal TPP for a tuberculosis triage test in this population. By contrast, RISK11 discriminated between asymptomatic controls and asymptomatic prevalent tuberculosis cases with an AUC of 0·75 (95% CI 0·66–0·84; figure 3).
In the secondary analysis of biomarker performance for incident tuberculosis, annualised incidence was 2·1 versus 0·8 per 100 person-years among the RISK11-positive versus RISK11-negative participants, respectively, which was equivalent to a 0·026 (95% CI 0·01–0·04) versus 0·010 (0·004–0·02) cumulative incident probability of developing tuberculosis disease over 15 months, respectively (figure 3). No incident tuberculosis cases were detected in RISK11-negative participants until 8·7 months (figure 3). Tuberculosis incidence through 15 months among RISK11-positive participants was 2·61 (95% CI 1·15–5·94) times higher than RISK11-negative participants (table 2); and the RISK11 signature discriminated between incident tuberculosis cases and controls with AUC of 0·63 (95% CI 0·47–0·80; figure 4). Over this period, at the predefined 60% threshold, RISK11 showed very low sensitivity of 25% (95% CI 12–46) with specificity of 91% (95% CI 91–91). At an exploratory RISK11 threshold of 26%, which provided 75% specificity, sensitivity was 47% (95% CI 26–74). By comparison, the prognostic sensitivity of IFNγ release assays over 15 months was 83% (62–100), but more than 60% of the population was IFNγ release assay positive (specificity 37%, 95% CI 35–40; table 2).Figure 4 Prognostic performance of RISK11 and treatment efficacy of 3HP
(A) ROC curve depicting RISK11 prognostic performance for incident tuberculosis through 15 months of follow-up. The shaded area represents 95% CI. The grey and black dots depict the minimum and optimal criteria, respectively, set out in the WHO target product profile for an incipient tuberculosis test. (B) RISK11 performance (area under the ROC curve) for endpoints within a 6-month sliding window from month 0 through 15. The shaded area represents 95% CI. (C) ROC curves depicting RISK11 prognostic performance for incident tuberculosis through expanding follow-up periods. The grey and black dots depict the minimum and optimal criteria, respectively, set out in the WHO target product profile for an incipient tuberculosis test. (D) Cumulative incidence of tuberculosis in RISK11-positive participants who were randomly assigned to 3HP (six cases, red line) and RISK11-positive participants who were randomly assigned to observation (14 cases, blue line) during follow-up. The shaded areas represent 95% CI. (E) Cumulative incidence of tuberculosis in participants who met criteria for treatment adherence per protocol, stratified into RISK11-positive participants who were randomly assigned to 3HP (four cases, red line) and RISK11-positive participants who were randomly assigned to observation (14 cases, blue line) during follow-up. (F) TE estimated through follow-up in participants who met criteria for treatment adherence per protocol. The shaded areas represent 95% CI. TRP=true positive rate. FPR=false positive rate. AUC=area under the receiver operating characteristic curve. TPP=target product profile. TE=treatment efficacy.
RISK11 prognostic performance was highly dependent on time to disease. Instantaneous RISK11 performance, estimated from 6-month sliding windows, showed prognostic discrimination was high (AUC >0·80) for approximately 9 months, before waning towards 0·58 between months 9 and 15 (figure 4; appendix p 16). Prognostic performance of RISK11 for incident tuberculosis within 6 months (AUC 0·95, 95% CI 0·92–1·0) exceeded the optimal TPP for an incipient tuberculosis test (appendix p 16), and for tuberculosis disease within 12 months (0·80, 0·65–0·94; figure 4) approached the minimum TPP (appendix p 16), but over a 15-month period did not meet minimum criteria for a prognostic tuberculosis test (table 2).
In the primary analysis of treatment efficacy among RISK11-positive participants, tuberculosis incidence in the 3HP-positive and 3HP-negative groups was 1·94 cases per 100 person years and 2·09 cases per 100 person years, respectively (figure 4; table 1), with estimated treatment efficacy of 7·0% (95% CI −145 to 64·7) over 15 months. In the subgroup of 286 adherent participants who completed at least 11 doses within 16 weeks, efficacy was 22% (−138 to 74; figure 4) over 15 months. Notably, among adherent participants, there were no tuberculosis cases through 9 months (figure 4).
Adverse events related to 3HP were mostly of mild to moderate severity (appendix p 12). 67 serious adverse events, including 29 due to trauma, occurred in 65 participants. Serious adverse events occurred in 20 (5·3%) of 375 RISK11-positive participants who received 3HP (eight serious adverse events due to trauma), compared with 12 (1·6%) of 764 in RISK11-positive and 3HP-negative participants (Fisher's exact p<0·001). Among RISK11-negative participants, 33 (1·9%) of 1784 experienced serious adverse events. All but two serious adverse events were deemed unrelated to 3HP. Serious adverse events related to 3HP included one hospitalisation for seizures (unintentional isoniazid overdose) and one death of unknown cause (possibly temporally related). One death of unknown cause also occurred in an untreated RISK11-negative participant. There were 16 deaths in total, including five RISK11-positive participants receiving 3HP (three deaths due to trauma), three untreated RISK11-positive participants, and eight RISK11-negative participants.
3HP was halted in 28 (7·5%) of 375 participants, due to an adverse event of special interest (influenza-like illness or other possible hypersensitivity reaction) in 17 (4·5%), hepatotoxicity in one (0·3%), gastrointestinal symptoms in three (0·8%), and seizures in three (0·8%) participants.
RISK11 diagnostic and prognostic performance and treatment efficacy of 3HP based on the secondary endpoint definition (at least one sputum sample; appendix p 14) are described in the appendix (p 15).
Five (8·2%) of the 61 participants witih prevalent tuberculosis were resistant to isoniazid or rifampicin, or both. Two (6·7%) of the 30 participants with incident tuberculosis, both in the untreated group, were resistant to isoniazid and rifampicin. No participants were observed to have drug-resistant incident tuberculosis in the 3HP-positive group.
Discussion
Our goal was to evaluate a biomarker-targeted, community-based strategy to detect missing tuberculosis cases among people who do not seek health care, whose disease might not be detected by symptom-focused screening algorithms, and to prevent disease among those at highest risk of progression to tuberculosis. The RISK11 assay was an effective screening test for active disease in symptomatic participants, in whom performance exceeded the requirements for a triage test, but less so in asymptomatic participants. The RISK11 signature was able to predict risk for tuberculosis disease progression, in a trial population with tuberculosis incidence exceeding one case per 100 person-years, but optimal prognostic performance was limited to a 6-month horizon. While risk-targeted 3HP did not prevent tuberculosis disease over 15 months, there was some evidence of transient efficacy through 9 months among fully adherent participants.
Community-based recruitment of ambulant volunteers was not focused on individuals with known risk factors for tuberculosis, such as household contact. Individuals with recent previous history of tuberculosis (>3 years before screening) and HIV infection were excluded. Nevertheless, more than 1% of study volunteers had previously undiagnosed, microbiologically confirmed tuberculosis at enrolment, based on spontaneous expectorated rather than induced sputum samples. More than 80% of these baseline tuberculosis cases did not have any symptom compatible with tuberculosis disease and would not have been detected by a tuberculosis screening strategy that requires symptoms as the entry point to investigation. This finding is consistent with 46–79% prevalence (median 50%) of subclinical tuberculosis reported in prevalence surveys.12, 13, 14 It is not known whether subclinical tuberculosis would have progressed to symptomatic disease, spontaneously halted, or even reversed if left untreated,15, 16 nor whether subclinical disease directly contributes to M tuberculosis transmission.17 Further research is needed to determine the importance of detection, treatment, and prevention of subclinical disease for global tuberculosis control.
Although very few prevalent tuberculosis cases were symptomatic, RISK11 performance for discrimination of symptomatic prevalent tuberculosis cases from symptomatic controls exceeded the optimal TPP criteria for a triage test, while not meeting the stringent criteria for a confirmatory diagnostic test.5 A 2020 prospective observational study among symptomatic individuals who self-presented to a tuberculosis clinic assessed diagnostic accuracy of 27 transcriptomic signatures for discrimination between prevalent tuberculosis cases and controls.18 The 16-gene Zak signature, from which RISK11 was derived, did not meet the minimum WHO criteria for a triage test, but four of the 27 signatures met these criteria, suggesting that another signature might perform as well as or better than RISK11. RISK11 discrimination of asymptomatic prevalent tuberculosis cases from asymptomatic controls was modest and did not meet the minimal criteria for a triage test. These findings suggest that host blood biomarker development must consider that subclinical tuberculosis might be characterised by more heterogenous or less pronounced peripheral blood inflammatory responses than symptomatic tuberculosis, or both, which affects RNA signature performance. This finding is consistent with lower inflammatory profiles, observed by blood transcriptomic and proteomic analyses, during the subclinical phases of tuberculosis progression compared with subsequent symptomatic, active disease.19, 20 The modest performance characteristics for asymptomatic prevalent tuberculosis would limit applicability of RISK11 for biomarker-targeted, mass community screening in the South African setting, where the majority of baseline tuberculosis cases were subclinical. A host blood biomarker with good sensitivity and specificity for symptomatic tuberculosis might be most useful in countries with low to medium tuberculosis burden, where individuals with compatible symptoms might not otherwise be investigated for tuberculosis. Future diagnostic studies in symptomatic patients seeking health care should also include patients with extrapulmonary and culture-negative tuberculosis, particularly in HIV-infected cohorts, and the full spectrum of differential diagnoses that commonly mimic tuberculosis.
Prognostic performance of RISK11 for risk of progression to incident tuberculosis was poor through 15 months and did not meet the minimum TPP criteria for an incipient tuberculosis test through this prognostic horizon.4 However, good prognostic performance was observed for incident tuberculosis within 12 months of testing and performance exceeded the optimal TPP criteria for tuberculosis occurring within 6 months of testing. The positive predictive value for incident disease (1·9 vs 0·9 for RISK11 compared with IFNγ release assay, respectively) was computed from the observed tuberculosis incidence rate, which was lower than that typically used in estimations (2%).3, 6 It is not possible to determine whether the late incident tuberculosis cases occurring among RISK11-negative participants were due to reactivation or new M tuberculosis infection. We infer that a prognostic test with optimal short-term performance might be useful in identifying people who would benefit from an efficacious intervention in a low-incidence setting, in which the timing of M tuberculosis exposure is often known and subsequent exposure is unlikely.
The 3HP regimen was previously shown to be as effective as 9 months of isoniazid in preventing tuberculosis among individuals with known exposure or positive TST.21 Ethical equipoise of the intervention and control groups in this trial was based on the fact that RISK11 had been validated in selected case-control studies, which can overestimate biomarker performance, and thus risk for tuberculosis among RISK11-positive individuals needed to be tested prospectively in the field. Furthermore, although TPT is given commonly to IFNγ release assay-positive and tuberculin skin test-positive individuals, and individuals with known household exposure to a tuberculosis patient, the vast majority do not progress to tuberculosis disease if left untreated. The risk–benefit balance of 3HP preventive therapy for RISK11-positive individuals was unknown. However, we found no evidence that 3HP treatment reduced the rate of incident tuberculosis over 15 months in RISK11-positive individuals, who might be further advanced along the spectrum of tuberculosis pathogenesis.19 Interpretation of the results is limited by the wide CIs. It is also notable that no tuberculosis cases were observed in fully adherent participants through 9 months. This finding is consistent with the possibility that 3HP was sufficient to temporarily halt, but insufficient to sterilise, incipient tuberculosis, resulting in reactivation. A RISK11-targeted preventive therapy strategy for high tuberculosis transmission settings like South Africa might require a more potent therapeutic regimen than 3HP. 3HP might have been sufficient to sterilise incipient tuberculosis disease, but not to protect against tuberculosis disease resulting from reinfection after completion of the treatment course. Although it is not possible to distinguish between reactivation and reinfection tuberculosis cases in this study, we suggest that the limited time available for reinfection and subsequent progression to disease after completing 3HP makes the latter possibility less likely.
The study was subject to a number of limitations. The hybrid design required an open-label treatment group,2 with no placebo for RISK11-positive participants, so that risk for tuberculosis could also be evaluated in the control group while concealing RISK11 status from participants, site staff, and tuberculosis endpoint laboratory staff for analysis of biomarker performance. Tuberculosis case accrual during the latter stages of follow-up suggested no evidence of ascertainment bias during treatment. Extensive study simulations were done to inform the size of each group for the coprimary analyses. However, due to lower than expected prevalence of RISK11-positive status in the screened population (9·3% vs 15%), enrolment of 1139 RISK11-positive individuals required 2 years, compared with planned enrolment of 1500 RISK11-positive individuals over 1 year. As a result, fewer than expected incident tuberculosis outcomes were observed (24 vs 40 primary endpoints), which might have reduced power for both treatment efficacy and RISK11 performance analyses. Not all participants in the treatment group completed 3HP per protocol, because study drug was discontinued for suspected hypersensitivity reactions or influenza-like illnesses. However, the discontinuation rate (7·5%) was comparable to other trials of 3HP, in which study drug was discontinued in 17·9% of participants overall and in 4·9% due to an adverse event.21 The loss to follow-up rate in this trial (14·4%) was higher than expected and might reflect the challenges of retaining the study participants, in the absence of traditional tuberculosis risk factors for which surveillance is routine. However, loss to follow-up occurred predominantly after the treatment period and did not seem to have been biased by treatment factors. We note that median duration of participation was 13·9 months and thus loss to follow-up did not have major unforeseen effect on statistical power. Strengths of the study include enrolment in geographically distinct sites across South Africa that were representative of populations with different rates of IFNγ release assay positivity and tuberculosis disease, which were congruent with local rates of RISK11 positivity, although the sample size was not sufficient for analysis of signature performance or 3HP efficacy at site level. The findings broadly reflect the South African tuberculosis epidemic, but might not be directly applicable to countries with much lower tuberculosis incidence.
It is not yet known whether other parsimonious tuberculosis signatures, developed and validated like RISK11 in carefully curated case-control studies, will exhibit similar performance characteristics when prospectively tested in the field, where undiagnosed subclinical tuberculosis might pose a challenge to diagnostic performance. Head-to-head analyses of several transcriptomic tuberculosis signatures with promising diagnostic performance are currently underway on CORTIS samples and novel near-patient testing platforms are in development, which might bring cost-effective, community-based tuberculosis biomarker screening closer to implementation in the field. However, although we have shown that a strategy of biomarker-guided tuberculosis preventive therapy is feasible, the optimal preventive therapy regimen for use in such a strategy remains elusive.
Data sharing
Deidentified RISK11 signature scores and primary tuberculosis endpoint data from all participants will be available with publication. The dataset is deposited in Zivahub (https://doi.org/10.25375/uct.13573337.v1), an open access data repository hosted by the University of Cape Town's institutional data repository powered by Figshare for Institutions.
Supplementary Material
Supplementary appendix
Acknowledgments
The trial was funded by the Bill & Melinda Gates Foundation (OPP1116632, OPP1137034) and the Strategic Health Innovation Partnerships Unit of the South African Medical Research Council with funds received from the South African Department of Science and Technology. Rifapentine was donated by the manufacturer (Sanofi). The authors thank the members of the data and safety monitoring board and the trial steering committee.
Contributors
TJS, AF-G, AP-N, SS, GW, KN, GC, and MH designed the study. CI, WB, AH, STM, RH-M, MT, GW, KN, and GC recruited and evaluated participants. TJS, AP-N, SKM, SCM, KH, MM, NB, ME, LJ, and RR collected and analysed laboratory data. AF-G, and BB accessed and verified the data. TJS, AF-G, AP-N, HM, BB, TS, RGW, and MH analysed data and interpreted results. KH, CH, and MK provided operational support. TJS, AF-G, HM, and MH drafted the Article. All authors had full access to the data, and reviewed, revised and gave final approval of the Article before submission.
The CORTIS-01 Study Team
Kesenogile Baepanye, Tshepiso Baepanye, Ken Clarke, Marelize Collignon, Audrey Dlamini, Candice Eyre, Tebogo Feni, Moogo Fikizolo, Phinda Galane, Thelma Goliath, Alia Gangat, Shirley Malefo-Grootboom, Elba Janse van Rensburg, Bonita Janse van Rensburg, Sophy Kekana, Marietjie Zietsman, Adrianne Kock, Israel Kunene, Aneessa Lakhi, Nondumiso Langa, Hilda Ledwaba, Marillyn Luphoko, Immaculate Mabasa, Dorah Mabe, Nkosinathi Mabuza, Molly Majola, Mantai Makhetha, Mpho Makoanyane, Blossom Makhubalo, Vernon Malay, Juanita Market, Selvy Matshego, Nontsikelelo Mbipa, Tsiamo Mmotsa, Sylvester Modipa, Samuel Mopati, Palesa Moswegu, Primrose Mothaga, Dorothy Muller, Grace Nchwe, Maryna Nel, Lindiwe Nhlangulela, Bantubonke Ntamo, Lawerence Ntoahae, Tedrius Ntshauba, Nomsa Sanyaka, Letlhogonolo Seabela, Pearl Selepe, Melissa Senne, MG Serake, Maria Thlapi, Vincent Tshikovhi, Lebogang Tswaile, Amanda van Aswegen, Lungile Mbata, Constance Takavamanya, Pedro Pinho, John Mdlulu, Marthinette Taljaard, Naydene Slabbert, Sharfuddin Sayed, Tanya Nielson, Melissa Senne, Ni Ni Sein, Lungile Mbata (The Aurum Institute); Dhineshree Govender, Tilagavathy Chinappa, Mbali Ignatia Zulu, Nonhle Bridgette Maphanga, Senzo Ralph Hlathi, Goodness Khanyisile Gumede, Thandiwe Yvonne Shezi, Jabulisiwe Lethabo Maphanga, Zandile Patrica Jali, Thobelani Cwele, Nonhlanhla Zanele Elsie Gwamanda, Celaphiwe Dlamini, Zibuyile Phindile Penlee Sing, Ntombozuko Gloria Ntanjana, Sphelele Simo Nzimande, Siyabonga Mbatha, Bhavna Maharaj, Atika Moosa, Cara-Mia Corris (Centre for the AIDS Programme of Research in South Africa); Fazlin Kafaar, Marwou De Kock, Hennie Geldenhuys, Angelique Kany Kany Luabeya, Justin Shenje, Natasja Botes, Susan Rossouw, Hadn Africa, Bongani Diamond, Samentra Braaf, Sonia Stryers, Alida Carstens, Ruwiyda Jansen, Simbarashe Mabwe, Roxane Herling, Ashley Veldsman, Lebohgang Makhete, Marcia Steyn, Sivuyile Buhlungu, Margareth Erasmus, Ilse Davids, Patiswa Plaatjie, Alessandro Companie, Frances Ratangee, Helen Veldtsman, Christel Petersen, Charmaine Abrahams, Miriam Moses, Xoliswa Kelepu, Yolande Gregg, Liticia Swanepoel, Nomsitho Magawu, Nompumelelo Cetywayo, Lauren Mactavie, Habibullah Valley, Elizabeth Filander, Nambitha Nqakala, Angelique Mouton, Fajwa Opperman, Elma Van Rooyen, Petrus Tyambetyu (South African Tuberculosis Vaccine Initiative, University of Cape Town); Elizna Maasdorp, Justine Khoury, Belinda Kriel, Bronwyn Smith, Liesel Muller, Susanne Tonsing, Andre Loxton, Andriette Hiemstra, Petri Ahlers, Marika Flinn (DST/NRF Centre of Excellence for Biomedical TB Research and SAMRC Centre for TB Research, Stellenbosch University); and Eva Chung, Michelle Chung, Alicia Sato (Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Research Center)
Declaration of interests
TJS has a patent of the RISK11 signature pending and reports grants from the Bill and Melinda Gates Foundation and South African Medical Research Council. KN reports grants from CAPRISA. GW reports a patent (PCT/IB2019/052043) pending to University of Cape Town, Stellenbosch University, Max-Planck-Gesellschaft Zur Foerderung Der Wissenschaften EV, Seattle Children's Hospital Doing Business as Seattle Children's Research Institute, and UK Research and Innovation. GC reports grants from the Bill & Melinda Gates Foundation. AP-N has a patent of the RISK11 signature pending and reports grants from the Bill & Melinda Gates Foundation and the South African Medical Research Council. MH reports grants from the Bill & Melinda Gates Foundation and the South African Medical Research Council. | Oral | DrugAdministrationRoute | CC BY | 33508224 | 20,168,180 | 2021-03 |
What was the administration route of drug 'RIFAPENTINE'? | Biomarker-guided tuberculosis preventive therapy (CORTIS): a randomised controlled trial.
Targeted preventive therapy for individuals at highest risk of incident tuberculosis might impact the epidemic by interrupting transmission. We tested performance of a transcriptomic signature of tuberculosis (RISK11) and efficacy of signature-guided preventive therapy in parallel, using a hybrid three-group study design.
Adult volunteers aged 18-59 years were recruited at five geographically distinct communities in South Africa. Whole blood was sampled for RISK11 by quantitative RT-PCR assay from eligible volunteers without HIV, recent previous tuberculosis (ie, <3 years before screening), or comorbidities at screening. RISK11-positive participants were block randomised (1:2; block size 15) to once-weekly, directly-observed, open-label isoniazid and rifapentine for 12 weeks (ie, RISK11 positive and 3HP positive), or no treatment (ie, RISK11 positive and 3HP negative). A subset of eligible RISK11-negative volunteers were randomly assigned to no treatment (ie, RISK11 negative and 3HP negative). Diagnostic discrimination of prevalent tuberculosis was tested in all participants at baseline. Thereafter, prognostic discrimination of incident tuberculosis was tested in the untreated RISK11-positive versus RISK11-negative groups, and treatment efficacy in the 3HP-treated versus untreated RISK11-positive groups, during active surveillance through 15 months. The primary endpoint was microbiologically confirmed pulmonary tuberculosis. The primary outcome measures were risk ratio [RR] for tuberculosis of RISK11-positive to RISK11-negative participants, and treatment efficacy. This trial is registered with ClinicalTrials.gov, NCT02735590.
20 207 volunteers were screened, and 2923 participants were enrolled, including RISK11-positive participants randomly assigned to 3HP (n=375) or no 3HP (n=764), and 1784 RISK11-negative participants. Cumulative probability of prevalent or incident tuberculosis disease was 0·066 (95% CI 0·049 to 0·084) in RISK11-positive (3HP negative) participants and 0·018 (0·011 to 0·025) in RISK11-negative participants (RR 3·69, 95% CI 2·25-6·05) over 15 months. Tuberculosis prevalence was 47 (4·1%) of 1139 versus 14 (0·78%) of 1984 in RISK11-positive compared with RISK11-negative participants, respectively (diagnostic RR 5·13, 95% CI 2·93 to 9·43). Tuberculosis incidence over 15 months was 2·09 (95% CI 0·97 to 3·19) vs 0·80 (0·30 to 1·30) per 100 person years in RISK11-positive (3HP-negative) participants compared with RISK11-negative participants (cumulative incidence ratio 2·6, 95% CI 1·2 to 5·9). Serious adverse events related to 3HP included one hospitalisation for seizures (unintentional isoniazid overdose) and one death of unknown cause (possibly temporally related). Tuberculosis incidence over 15 months was 1·94 (95% CI 0·35 to 3·50) versus 2·09 (95% CI 0·97 to 3·19) per 100 person-years in 3HP-treated RISK11-positive participants compared with untreated RISK11-positive participants (efficacy 7·0%, 95% CI -145 to 65).
The RISK11 signature discriminated between individuals with prevalent tuberculosis, or progression to incident tuberculosis, and individuals who remained healthy, but provision of 3HP to signature-positive individuals after exclusion of baseline disease did not reduce progression to tuberculosis over 15 months.
Bill and Melinda Gates Foundation, South African Medical Research Council.
Introduction
Large-scale prevention of progression from Mycobacterium tuberculosis infection to tuberculosis disease is key to achieving WHO End TB Strategy targets, yet tuberculin skin tests (TST) and interferon (IFN) γ release assays have poor specificity for incident tuberculosis.1 A biomarker-targeted prevention strategy using a highly specific correlate of risk (COR) for incident tuberculosis, in tandem with effective short-course tuberculosis preventive therapy (TPT),2 might impact the epidemic by preventing incident tuberculosis disease before transmission.3 Modelling suggests a three-times reduction in burden of TPT if targeted by COR, compared with IFNγ release assays and TST.4 Furthermore, because active tuberculosis disease should be excluded before starting TPT, additional utility of the prognostic COR as a screening (triage) test to identify undiagnosed tuberculosis disease would allow earlier curative treatment. WHO and FIND have developed target product profiles (TPP) for triage tests for tuberculosis (optimal and minimum sensitivity of >95% and >90%, and specificity of >80% and >70%, respectively),5 and incipient tuberculosis tests (minimum sensitivity and specificity of 75% and 75%, and optimal sensitivity and specificity of 90% and 90%, respectively).6
Research in context
Evidence before this study
Host blood RNA signatures have potential as tuberculosis triage or diagnostic tests, and as predictive tests to target tuberculosis preventive therapy. We searched MEDLINE, Scopus, Web of Science, and EBSCO libraries for publications between Jan 1, 2005, and May 31, 2020, using the search terms “Tuberculosis” OR “TB” OR “Mycobacterium tuberculosis” OR “MTB” AND “diagnosis” OR “diagnostic” OR “detect” OR “predic”OR “prognosis” OR “prognostic” OR “screen” AND “Blood Biomarker” OR “blood biomarkers” OR “bio-signature” OR “gene expression” OR “genetic transcription” OR “host blood” OR “immune marker” OR “immunologic marker” OR “Ribonucleic Acid” OR “RNA” OR “signature” OR “surrogate endpoint” OR “surrogate marker” OR “transcriptome” OR “transcriptomic” AND “Area under curve” OR “AUC” OR “receiver operating characteristic” OR “ROC” OR “Accuracy” OR “Performance” OR “sensitivity” OR “specificity”. Studies comparing blood RNA signatures in individuals with tuberculosis versus Mycobacterium tuberculosis-uninfected controls, individuals with other respiratory diseases, or with M tuberculosis infection and using a microbiological reference standard of either sputum M tuberculosis culture, Xpert MTB/RIF, or smear microscopy for tuberculosis diagnosis, were included.
28 studies reported evaluation of 32 host blood RNA signatures for diagnosis or prediction of progression to tuberculosis disease in 83 cohorts. Only two studies prospectively tested performance of an RNA signature in all evaluable participants; the remainder used a case-control design. Multiple studies have tested tuberculosis preventive therapy in people with M tuberculosis latent tuberculosis infection. No studies have tested efficacy of tuberculosis preventive therapy to avert disease in RNA signature-positive people.
Added value of this study
This large randomised, controlled trial in five South African communities prospectively tested diagnostic and prognostic performance of an RNA signature (RISK11) in all evaluable participants, and estimated efficacy of tuberculosis preventive therapy to avert disease in RNA signature-positive people. More than 1% of HIV-uninfected community volunteers had previously undiagnosed, microbiologically confirmed tuberculosis at screening, more than 80% of which was asymptomatic. RISK11 showed moderate performance for tuberculosis triage, but good performance for diagnosis of symptomatic tuberculosis, and for short-term prediction of incident tuberculosis. 3 months of once-weekly, high-dose isoniazid and rifapentine (3HP) did not reduce incident disease in RISK11-positive individuals over 15 months of follow-up.
Implications of all the available evidence
Host blood biomarker development must consider that subclinical tuberculosis might be characterised by more heterogenous, or less pronounced blood inflammatory responses than symptomatic tuberculosis, or both, which will affect RNA signature performance. RISK11 might be better suited to screening of symptomatic individuals with possible tuberculosis than for mass community-based screening. RISK11 can identify those at highest risk for short-term progression to disease, but a more potent regimen than 3HP might be needed to prevent tuberculosis in RISK11-positive individuals.
We previously developed a 16-gene transcriptomic signature by whole blood RNA sequencing for identification of individuals at high risk of developing tuberculosis (the Zak16 signature).7, 8 Measurement of Zak16 was adapted to quantitative RT-PCR (RT-qPCR), and predictive ability for incident tuberculosis was validated in an independent longitudinal cohort of household contacts of tuberculosis patients.8 We reduced this signature to 11 genes (RISK11) with equivalent performance,9, 10 to allow testing in 96-well PCR format. Zak16 and RISK11 also did well as non-sputum screening tests for prevalent, active tuberculosis in case-control studies, measured by RNA sequencing, microarray,7, 8 or microfluidic RT-qPCR.9, 10 In a 2020 systematic review and patient-level pooled meta-analysis of 17 transcriptomic signatures for prognosis of incident tuberculosis, Zak16 was among eight signatures that achieved a positive predictive value above the WHO TPP benchmark for incipient tuberculosis tests.11 Since case-control studies might overestimate performance characteristics, testing in unselected populations is needed.
We report on a randomised controlled trial (CORTIS; NCT02735590), which prospectively measured diagnostic and prognostic performance of RISK11 for triage of prevalent and prediction of incident tuberculosis in South African adults; and, in parallel, estimated efficacy of short-course TPT to avert incident disease in RISK11-positive individuals.
Methods
Study design
This randomised controlled trial used a hybrid treatment selection, three-group study design to evaluate efficacy of the intervention and, in parallel, performance of the biomarker used to allocate that intervention (figure 1).2 The coprimary aims were to test, over 15 months, whether RISK11 status differentiates between people with and without cumulative prevalent or incident tuberculosis; and whether preventive therapy (weekly high-dose isoniazid and rifapentine for 12 weeks [3HP]) reduces tuberculosis incidence among RISK11-positive people compared with active surveillance only. RISK11 performance to detect prevalent tuberculosis was evaluated in all groups at baseline. RISK11 performance to predict incident tuberculosis was evaluated in the untreated RISK11-positive and RISK11-negative groups, and treatment efficacy was estimated from the 3HP treated and untreated RISK11-positive groups, after omitting participants with baseline tuberculosis. Efficiency of the hybrid study design was maximised by using the RISK11-positive and 3HP-negative group to evaluate both biomarker performance and treatment efficacy.Figure 1 Study design
The prevalence of RISK11 positivity was not precisely known in the study population; therefore, the number of individuals to be screened and the randomisation of RISK11-negative participants to enrolment was monitored and adjusted adaptively to ensure concurrent enrolment of the target number of RISK11-positive and RISK11-negative participants, per protocol specifications. The study used a three-group design to evaluate efficacy of the intervention and, in parallel, performance of the biomarker used to allocate that intervention. Diagnostic performance for differentiation of prevalent tuberculosis was tested in all three groups at baseline; prognostic performance for differentiation of incident tuberculosis over 15 months was tested in the two untreated groups (untreated RISK11 positive and untreated RISK11 negative); and treatment efficacy of 3HP over 15 months was tested in the two RISK11-positive groups (treated and untreated RISK11 positive). *Participants evaluated for eligibility at screening and enrolment. †Groups randomly assigned in blocks to ensure concurrent enrolment.
Routine implementation of TPT requires that patients are screened to exclude prevalent tuberculosis before TPT is provided to prevent incident disease. Therefore, because risk for prevalent and incident tuberculosis by RISK11 status must be understood before efficacy of preventive therapy against incident tuberculosis in RISK11-positive people can be interpreted, these secondary analyses are presented before the primary analysis of treatment efficacy.
The trial protocol (appendix p 21) was approved by the South African Health Products Regulatory Agency (20160305) by the Institutional Human Ethics Committees of participating sites; and was registered on ClinicalTrials.gov (NCT02735590). All participants provided written informed consent in their language of choice.
Participants
Adult volunteers living in tuberculosis-endemic communities in South Africa were recruited at five sites (South African Tuberculosis Vaccine Initiative, Worcester; Immunology Research Group, Stellenbosch University, Ravensmead; Aurum Institute, Klerksdorp and Rustenberg; and Centre for the AIDS Programme of Research in South Africa, Durban). Community-based recruitment was by word-of-mouth, house-to-house visits, and liaison with non-governmental organisations. Recruitment did not target groups at high risk of tuberculosis, such as household contacts. Eligible participants were aged between 18 years and 59 years, HIV-negative, without a history of tuberculosis disease in the last 3 years or preselected comorbidities (appendix p 8).
Screening
Venous blood was collected in PAXgene RNA tubes from all potentially eligible people at screening, frozen at −20°C, and shipped weekly to the South African Tuberculosis Vaccine Initiative Immunology Laboratory for RISK11 testing by qRT-PCR assay. Participants with a RISK11 score of at least 60% were classified a priori as RISK11 positive and less than 60% as RISK11 negative. This 60% threshold was the optimal point at which sensitivity and specificity for prognosis of incident tuberculosis were balanced in case-control studies.2 Samples with failed reference primer-probe reactions, with marked deviation in internal positive control sample from historical runs, or more than 30% failed interferon-stimulated genes primer-probe reactions (see quality control criteria and analysis script in Bitbucket instance) were classified as indeterminate. Per-participant qualitative results (RISK11 positive and RISK11 negative) were provided to the Triclinium Clinical Development (TCD) Data Centre for participant randomisation (see appendix pp 2–3).
Randomisation and masking
Assignment to study group was managed by an unmasked randomisation team from the TCD Data Centre, based on RISK11 status. RISK11-positive volunteers were randomly assigned (1:2; block size 15) to either open-label 3HP (3HP-positive group), or active tuberculosis surveillance without 3HP (3HP-negative group), in accordance with a randomisation schedule generated using SAS, version 9.4. RISK11-negative volunteers were concurrently randomly assigned either to active tuberculosis surveillance (3HP-negative group) or to non-participation, to enrich the study population for RISK11-positive participants.
Study group allocation was revealed to site staff after enrolment of eligible participants within 28 days of screening. The 3HP-negative group was double-blinded to RISK11 status, but unblinded to treatment allocation; the 3HP-positive group was unblinded to both RISK11-positive status and treatment allocation (figure 1). RISK11-positive participants randomly assigned to active surveillance did not receive a placebo, to maintain blinding of participants and study team members to RISK11 status.
Procedures
Target enrolment was maximally 3200 participants (1500 RISK11 positive and 1700 RISK11 negative). The randomisation ratio for RISK11-negative volunteers was adapted to ensure concurrent enrolment of the recruitment target. Adaptations occurred at intervals, informed by 3-monthly operational monitoring reports based on enrolment rate, RISK11-positive and RISK11-negative prevalence, and tuberculosis case accrual blinded to RISK11 status (appendix p 7).
Enrolment procedures included phlebotomy for IFNγ release assays (QuantiFERON TB Gold-Plus, Qiagen), tuberculosis symptom screen (a positive tuberculosis symptom screen included one or more symptoms of persistent unexplained cough, fever, night sweats, weight loss, or any haemoptysis), and collection of two spontaneous expectorated sputum samples for Xpert MTB/RIF assay (Cepheid) from all sputum-productive participants, regardless of symptoms.
All participants attended up to seven study visits, including four study site visits at months 3, 6, 12, and 15 (end of study), and three telephonic contact or field visits at months 1, 2, and 9. HIV testing was repeated at months 6 and 12.
Participants in the 3HP group received open-label, high-dose isoniazid (15 mg/kg; maximum dose 900 mg) with pyridoxine supplementation (25 mg) and rifapentine based on body weight (>32–50 kg, 750 mg; >50 kg, 900 mg), given weekly as directly observed oral doses, ideally with food, over 12 weeks. Completion of 3HP treatment was defined as receipt of 11 doses within 16 weeks (appendix p 3).
Outcomes
The two primary outcome measures were RISK11-positive to RISK11-negative risk ratio (RR) for prevalent or incident tuberculosis disease, and 3HP treatment efficacy through 15 months. Diagnostic performance for prevalent tuberculosis was evaluated on the presence of tuberculosis at the enrolment visit within the ITT cohort.
Participants in the 3HP group had each dose directly observed by study staff, and attended clinic for evaluation of solicited adverse events and possible adverse events of special interest at weeks 1–11. Solicited adverse events included gastrointestinal signs and symptoms suggestive of hepatotoxicity, such as nausea, vomiting, and jaundice. Possible hypersensitivity reactions, including influenza-like illness, were reported as adverse events of special interest. Safety events meeting the definition for a serious adverse event, whether deemed related or unrelated to study drug, were reported for both all participants through end of study.
Statistical analysis
The intention-to-treat (ITT) cohort included all enrolled participants who completed investigation for tuberculosis endpoints at baseline. The modified intention-to-treat (mITT) cohort included all participants in the ITT population who completed at least one post-baseline tuberculosis endpoint investigation and omitted participants with endpoint-defined tuberculosis disease at baseline (prevalent tuberculosis).
The diagnostic RR was estimated as a proportion of participants with tuberculosis disease among RISK11-positive divided by RISK11-negative participants. Prognostic performance for incident tuberculosis after enrolment was evaluated among 3HP-negative participants within the mITT cohort (ie, excluding participants with tuberculosis at baseline). Prognostic RR was estimated as the cumulative incidence through 15 months for RISK11-positive divided by RISK11-negative participants. The primary RR was an estimate of the probability of having prevalent tuberculosis or developing incident tuberculosis among RISK11-positive divided by RISK11-negative participants; this combined probability of prevalent and incident tuberculosis was computed for each group as the probability of prevalent tuberculosis plus the probability of incident tuberculosis through 15 months (conditioned on not having prevalent tuberculosis). Efficacy of 3HP preventive therapy to reduce the rate of incident tuberculosis disease compared with the untreated RISK11-positive participants was also evaluated in the mITT population. Treatment efficacy was estimated as one minus the cumulative incidence of RISK11-positive and 3HP-positive participants divided by RISK11-positive and 3HP-negative participants through 15 months. A per-protocol analysis of treatment efficacy was done and excluded RISK11-positive and 3HP-positive participants that received less than 11 of the 12 weekly doses of 3HP.
For statistical efficiency, a random subset of RISK11-negative participants were enrolled, therefore creating an ITT cohort artificially enriched with RISK11-positive participants. Therefore, unless stated otherwise, all analyses were adjusted so that results reflected the screened population. Secondary performance metrics such as sensitivity and specificity were estimated using standard formulas with binary endpoints; a percentile bootstrap with 20 000 samples was used to estimate 95% CIs. For descriptive analyses (Table 1, Table 2), rank-based Wilcoxon rank-sum tests were used to compare continuous variables in RISK11-positive versus RISK11-negative groups. Fisher's exact test was used to compare binary readouts; p values in Table 1, Table 2 were not adjusted for multiple comparisons. The prespecified statistical analysis plan is included in the appendix (p 82) and contains detailed description of the statistical methods.Table 1 Baseline characteristics and primary tuberculosis endpoints by group
Total (n=2923) RISK11 positive and 3HP positive (n=375) RISK11 positive and 3HP negative (n=764) RISK11 negative (n=1784) RISK11 positive vs RISK11 negative, p value*
Sex
Female 1585 (54·2%) 213 (56·8%) 469 (61·4%) 903 (50·6%) <0·001
Male 1338 (45·8%) 162 (43·2%) 295 (38·6%) 881 (49·4%) ..
Age, years 28·5 (9·0) 28·8 (9·5) 28·4 (9·2) 28·4 (8·7) 0·541
Race or ethnicity
Asian 4 (0·1%) 0 1 (0·1%) 3 (0·2%) 0·567
Black African 1947 (66·6%) 227 (60·5%) 477 (62·4%) 1243 (69·7%) <0·001
White 4 (0·1%) 0 1 (0·1%) 3 (0·2%) 0·567
Mixed race 968 (33·1%) 148 (39·5%) 285 (37·3%) 535 (30·0%) <0·001
Body-mass index, kg/m2 24·6 (7·7) 24·1 (6·3) 24·4 (6·1) 24·9 (8·6) 0·354
Previous tuberculosis 230 (7·9%) 36 (9·6%) 75 (9·8%) 119 (6·7%) 0·003
Smoking 1478 (50·6%) 203 (54·1%) 391 (51·2%) 884 (49·6%) 0·170
Family tuberculosis history 462 (15·8%) 66 (17·6%) 110 (14·4%) 286 (16·0%) 0·675
Interferon γ release assay positive 1895 (64·8%) 250 (66·7%) 528 (69·1%) 1117 (62·6%) <0·001
Follow-up, months 15 (9·4–15·0) 15 (11·1–15·0) 15 (9·1–15·0) 13·6 (9·4–15·0) 0·056
Prevalent tuberculosis, n (probability, 95% CI) 61 (1·1%, 0·77–1·6)† 47 (4·1%, 3·1–5·4)‡ 47 (4·1%, 3·1–5·4)§ 14 (0·78%, 0·47–1·3) NA
Incident tuberculosis, n (cases per 100 person years, 95% CI) 24 (1·05, 0·59–1·5)§ 6 (1·9, 0·35–3·5) 14 (2·09, 0·97–3·19) 10 (0·80, 0·30–1·30) NA
Cumulative tuberculosis, n (probability, 95% CI)¶ 85 (0·022, 0·016–0·028)† 61 (0·066, 0·049–0·084)‖** 61 (0·066, 0·049–0·084)** 24 (0·018, 0·011–0·026) NA
Data are n (%), mean (SD), or median (IQR), unless stated otherwise. Secondary tuberculosis endpoints by group are in the appendix (p 13). NA=not applicable.
* For continuous data, p values from Wilcoxon rank sum test. For categorical data, p values from Fischer's exact test.
† Overall rate estimates are weighted combinations of the enrolled participants to reflect the screened population.
‡ Overall incidence and cumulative tuberculosis excludes RISK11-positive and 3HP-positive incident cases.
§ Prevalent tuberculosis among RISK11 positive was assessed by combining the 3HP-negative and 3HP-positive groups. Value is repeated for RISK11 positive and 3HP positive, and RISK11 positive and 3HP negative.
¶ Probability of observing prevalent or incident tuberculosis over 15 months.
‖ Probability of prevalent or incident tuberculosis not estimated for RISK11-positive and 3HP-positive because it would combine data from before and after 3HP treatment and is therefore potentially misleading.
** Estimate for RISK11 positive includes 3HP-positive prevalent cases and 3HP-negative prevalent and incident cases. Value is repeated for RISK11 positive and 3HP positive, and RISK11 positive and 3HP negative.
Table 2 Performance of RISK11 and IGRA for prevalent and incident tuberculosis
Prevalent tuberculosis (ITT cohort) Incident tuberculosis (mITT cohort)*
RISK11 (60)† RISK11 (26)† IGRA RISK11 (60)† RISK11 (26)† IGRA
Risk ratio 5·13 (2·93 to 9·43) 7·39 (3·46 to 25·69) 4·43 (1·93 to 14·18) 2·61 (1·15 to 5·94) 2·67 (1·04 to 8·66) 2·83 (0·95 to 99·79)
Biomarker prevalence 9·2% (9·2 to 9·2) 25·8% (24·1 to 27·4) 63·4% (61·3 to 65·4) 9·0% (9·0 to 9·0) 25·3% (23·7 to 26·9) 63·2% (61·1 to 65·3)
AUC‡ 0·77 (0·68 to 0·86) .. 0·66 (0·58 to 0·73) 0·63 (0·47 to 0·80) .. 0·67 (0·54 to 0·79)
Sensitivity 34·9% (23·7 to 52·2) 72·1% (54·5 to 90·2) 88·7% (77·1 to 96·4) 25·0% (12·7 to 45·9) 47·5% (25·9 to 75·0) 83·2% (61·9 to 100·0)
Specificity 91·0% (90·9 to 91·1) 74·7% (73·1 to 76·4) 36·9% (34·9 to 39·0) 91·1% (91·0 to 91·2) 74·9% (73·2 to 76·5) 37·0% (34·9 to 39·1)
PPV§ 4·1% (3·0 to 5·4) 3·1% (2·0 to 4·3) 1·5% (1·0 to 2·2) 1·9% (0·9 to 3·0) 1·3% (0·6 to 2·1) 0·9% (0·5 to 1·4)
PPV (2% incidence)¶ .. .. .. 6·7% (3·5 to 11·8) 4·6% (2·5 to 7·1) 3·3% (2·5 to 3·9)
NPV§ 99·2% (98·8 to 99·6) 99·6% (99·2 to 99·9) 99·7% (99·3 to 99·9) 99·4% (99·0 to 99·8) 99·5% (99·1 to 99·9) 99·7% (99·2 to 100·0)
NPV (2% incidence)¶ .. .. .. 97·9% (97·6 to 98·5) 98·2% (97·5 to 99·2) 98·8% (97·4 to 100·0)
NNS or NNT‖ 29·9 (21·8 to 46·6) 37·8 (25·5 to 65·7) 83·1 (53·2 to 179·8) 75·1 (40·4 to 277·5) 123·8 (47·2 to 834·1) 168 (−440 to 1059)
Data are risk ratio (95 %CI), % (95% CI), AUC (95% CI), or NNS or NNT (95% CI). ITT=intention to treat. mITT=modified intention-to-treat. IGRA=interferon γ release assay. AUC=area under the receiver operating characteristic curve. PPV=positive predictive value. NPV=negative predictive value. NNS=number needed to screen. NNT=number needed to treat.
* Computed over 15-month prognostic window. Performance of RISK11 and IGRA for incident tuberculosis over 6-month and 12-month prognostic windows is in the appendix (p 16).
† RISK11 score threshold at 60% or 26%.
‡ AUC is computed across all score thresholds and value is presented under RISK11 (60).
§ Computed using the prevalence and incidence rates in the trial population as appropriate.
¶ Computed assuming 2% annual incidence of tuberculosis in the population.
‖ NNS for prevalent tuberculosis; NNT for incident tuberculosis. Performance of RISK11 and IGRA for prevalent and incident tuberculosis based on secondary endpoint (≥1 sample+) is in the appendix (p 15).
The study was designed to have 90% power to reject the null hypothesis of a RISK11-positive and RISK11-negative cumulative risk ratio less than 2 with one-sided alpha of 0·025. For treatment efficacy there was 80% power to reject the null hypothesis of efficacy less than 20%, with one-sided alpha of 0·05 and under the alternative design hypothesis that efficacy was 80%. To compute statistical power for these aims, a stochastic simulation of the trial was constructed, based on which we expected to observe 33 tuberculosis disease endpoints among 1500 RISK11-positive participants and seven tuberculosis disease endpoints among 1700 RISK11-negative participants (appendix p 6).
Role of the funding source
The trial was funded by the Bill & Melinda Gates Foundation (OPP1116632, OPP1137034) and the Strategic Health Innovation Partnerships Unit of the South African Medical Research Council, with funds received from the South African Department of Science and Technology. The Gates Foundation contributed to the study design. The regulatory sponsor was the University of Cape Town. Rifapentine (PRIFTIN) was donated by the manufacturer (Sanofi), who had no role in the design, implementation, analysis, or reporting of the trial. All authors had access to all the data reported in the study. The corresponding author had final responsibility for the decision to submit for publication.
Results
Between Sept 20, 2016, and Oct 19, 2018, 20 207 volunteers consented to participation; 16 248 met inclusion criteria at screening and 15 777 with a RISK11 result were potentially eligible for enrolment (figure 2). Of the 20 207 adults assessed for eligibility, common reasons for exclusion included HIV infection (1246 [6·1%]) and comorbid conditions (1369 [6·8%]; appendix p 8). 2923 eligible participants were enrolled after randomisation (1784 [61·0%] RISK11 negative and 1139 [39·0%] RISK11 positive; table 1).Figure 2 Trial profile
ITT=intention to treat. mITT=modified intention to treat. LTFU=lost to follow-up. PP=per protocol analysis. *585 participants did not complete the trial for reasons including: 53 (9%) pregnancies, 22 (4%) investigator withdrawals, 46 (8%) consent withdrawals, 26 (4%) HIV infections, 422 (72%) LTFU, and 16 (3%) deaths.
Participants were enrolled at five geographically diverse sites across South Africa (appendix pp 9–11). Among participants with a RISK11 result, 1434 (9·3%) of 15 494 were RISK11 positive, with the proportion ranging from 6·2% to 13·0% across the five sites. RISK11-positive participants were randomly asigned either to receive treatment (375 [32·9%] RISK11 positive and 3HP positive) or undergo observation without treatment (764 [67·1%] RISK11 positive and 3HP negative).
There were no significant differences in smoking history, family history of tuberculosis, or febrile illness between RISK11-positive and RISK11-negative participants (table 1). A higher proportion of RISK11-positive (75 [9·8%] of 364) than RISK11-negative (119 [6·7%] of 1784) participants reported previous tuberculosis disease (p=0·003). Compared with RISK11 negative participants, a greater proportion of RISK11-positive participants were female and mixed race (p<0·001; table 1).
Median duration of follow-up for incident tuberculosis was 13·9 months (IQR 9·0–15·0) and 1879 (66%) of 2500 3HP-negative mITT participants attended at least six scheduled visits. 1416 (49%) of 2838 participants were followed up for 15 months and 2160 (75%) of 2838 participants were followed up for at least 9 months. 585 (21%) of 2838 participants did not complete the study because of withdrawal, death, or loss to follow-up (figure 2; table 1).
Among 91 participants with tuberculosis who reached the primary endpoint, 61 were diagnosed with prevalent tuberculosis at baseline (47 RISK11 positive and 14 RISK11 negative; table 1; appendix p 13). Prevalence of tuberculosis in RISK11-positive and RISK11-negative participants was 4·1% (95% CI 3·1–5·4) and 0·78% (0·5–1·3), respectively (figure 3). Thereafter, 24 participants in the untreated group were diagnosed with incident tuberculosis disease (14 RISK11 positive and ten RISK11 negative; table 1; appendix p 13) with overall incidence of 1·05 cases (95% CI 0·59–1·5) per 100 person-years.Figure 3 RISK11 detection of combined prevalent and incident tuberculosis and diagnostic performance
(A) Prevalence of tuberculosis in RISK11-positive (47 cases,) and RISK11-negative (14 cases, red bar) participants at trial enrolment. Error bars depict 95% CI. Cumulative incidence probability of tuberculosis in RISK11-positive (14 cases, blue line) or RISK11-negative (10 cases, red line) mITT participants during follow-up. Shaded areas represent 95% CI. (B) Ratio of RISK11-positive versus RISK11 negative cumulative incidence probability of observing prevalent or incident tuberculosis disease, in the ITT population of the observation group. (C) RISK11 signature scores (each dot represents a participant) measured at screening in trial participants, stratified on tuberculosis diagnosis. Boxes depict IQR, midline represents the median, and whiskers indicate range among enrolled participants. (D) RISK11 signature scores measured at screening in prevalent tuberculosis cases with or without any tuberculosis symptoms, in incident tuberculosis cases or those who did not have a tuberculosis diagnosis. The enrolled population, not the screened population, is represented in (C) and (D), because a large fraction of RISK11-negative participants were not enrolled by design. (E) ROC curves depicting RISK11 diagnostic performance for prevalent tuberculosis in the ITT population, for prevalent tuberculosis among individuals with no symptoms of tuberculosis (asymptomatic) and among individuals with at least one symptom consistent with tuberculosis disease (symptomatic). Shaded areas represent the 95% CI. The grey and black dots indicate the minimum and optimal criteria, respectively, set out in the WHO target product profile for a triage test. The empty dot indicates the criteria set out in the WHO target product profile for a confirmatory diagnostic test. TRP=true positive rate. ITT=intention to treat. FPR=false positive rate. AUC=area under the receiver operating characteristic curve.
In the primary analysis of biomarker performance for cumulative tuberculosis, cumulative probability of observing prevalent or incident tuberculosis disease in the ITT population was 0·066 (95% CI 0·049–0·084) in RISK11-positive participants and 0·018 (0·011–0·025) in RISK11-negative participants, with a risk ratio of 3·69 (95% CI 2·25–6·05) over 15 months (figure 3).
A wide range of RISK11 scores was observed, irrespective of tuberculosis outcome (figure 3). Among enrolled participants, those who remained tuberculosis free (controls) had significantly lower RISK11 scores (24·2%, IQR 8·2–75·3) than those with prevalent or incident tuberculosis disease (76·7%, 36·6–94·4; Wilcoxon rank-sum test p<0·0001; figure 3).
In the secondary analysis of biomarker performance for prevalent tuberculosis, using the prespecified RISK11 test threshold (60%) there was 5·13-times (95% CI 3·01–10·69) increased risk of prevalent tuberculosis disease at baseline in RISK11-positive versus RISK11-negative participants, with sensitivity of 35% (95% CI 24–52) and specificity of 91% (95% CI 91–91; table 2). The receiver operating characteristic (ROC) analysis (figure 3) showed that a RISK11 threshold of 26% provided sensitivity of 72% (95% CI 54–90) and specificity of 75% (95% CI 73–76; table 2); with area under the diagnostic ROC curve (AUC) of 0·77 (95% CI 0·68–0·86). These performance estimates did not meet the minimum criteria for a tuberculosis triage test (table 2). 50 (83·6%) of 61 participants with prevalent tuberculosis had no symptoms compatible with tuberculosis disease, and the remaining 11 participants with at least one symptom consistent with tuberculosis had RISK11 scores of more than 80% (median 96%; figure 3; appendix p 14). Discrimination between symptomatic prevalent tuberculosis and symptomatic controls was high (AUC 0·97, 95% CI 0·95–0·99; figure 3) and, with a highly specific threshold, performance exceeded the optimal TPP for a tuberculosis triage test in this population. By contrast, RISK11 discriminated between asymptomatic controls and asymptomatic prevalent tuberculosis cases with an AUC of 0·75 (95% CI 0·66–0·84; figure 3).
In the secondary analysis of biomarker performance for incident tuberculosis, annualised incidence was 2·1 versus 0·8 per 100 person-years among the RISK11-positive versus RISK11-negative participants, respectively, which was equivalent to a 0·026 (95% CI 0·01–0·04) versus 0·010 (0·004–0·02) cumulative incident probability of developing tuberculosis disease over 15 months, respectively (figure 3). No incident tuberculosis cases were detected in RISK11-negative participants until 8·7 months (figure 3). Tuberculosis incidence through 15 months among RISK11-positive participants was 2·61 (95% CI 1·15–5·94) times higher than RISK11-negative participants (table 2); and the RISK11 signature discriminated between incident tuberculosis cases and controls with AUC of 0·63 (95% CI 0·47–0·80; figure 4). Over this period, at the predefined 60% threshold, RISK11 showed very low sensitivity of 25% (95% CI 12–46) with specificity of 91% (95% CI 91–91). At an exploratory RISK11 threshold of 26%, which provided 75% specificity, sensitivity was 47% (95% CI 26–74). By comparison, the prognostic sensitivity of IFNγ release assays over 15 months was 83% (62–100), but more than 60% of the population was IFNγ release assay positive (specificity 37%, 95% CI 35–40; table 2).Figure 4 Prognostic performance of RISK11 and treatment efficacy of 3HP
(A) ROC curve depicting RISK11 prognostic performance for incident tuberculosis through 15 months of follow-up. The shaded area represents 95% CI. The grey and black dots depict the minimum and optimal criteria, respectively, set out in the WHO target product profile for an incipient tuberculosis test. (B) RISK11 performance (area under the ROC curve) for endpoints within a 6-month sliding window from month 0 through 15. The shaded area represents 95% CI. (C) ROC curves depicting RISK11 prognostic performance for incident tuberculosis through expanding follow-up periods. The grey and black dots depict the minimum and optimal criteria, respectively, set out in the WHO target product profile for an incipient tuberculosis test. (D) Cumulative incidence of tuberculosis in RISK11-positive participants who were randomly assigned to 3HP (six cases, red line) and RISK11-positive participants who were randomly assigned to observation (14 cases, blue line) during follow-up. The shaded areas represent 95% CI. (E) Cumulative incidence of tuberculosis in participants who met criteria for treatment adherence per protocol, stratified into RISK11-positive participants who were randomly assigned to 3HP (four cases, red line) and RISK11-positive participants who were randomly assigned to observation (14 cases, blue line) during follow-up. (F) TE estimated through follow-up in participants who met criteria for treatment adherence per protocol. The shaded areas represent 95% CI. TRP=true positive rate. FPR=false positive rate. AUC=area under the receiver operating characteristic curve. TPP=target product profile. TE=treatment efficacy.
RISK11 prognostic performance was highly dependent on time to disease. Instantaneous RISK11 performance, estimated from 6-month sliding windows, showed prognostic discrimination was high (AUC >0·80) for approximately 9 months, before waning towards 0·58 between months 9 and 15 (figure 4; appendix p 16). Prognostic performance of RISK11 for incident tuberculosis within 6 months (AUC 0·95, 95% CI 0·92–1·0) exceeded the optimal TPP for an incipient tuberculosis test (appendix p 16), and for tuberculosis disease within 12 months (0·80, 0·65–0·94; figure 4) approached the minimum TPP (appendix p 16), but over a 15-month period did not meet minimum criteria for a prognostic tuberculosis test (table 2).
In the primary analysis of treatment efficacy among RISK11-positive participants, tuberculosis incidence in the 3HP-positive and 3HP-negative groups was 1·94 cases per 100 person years and 2·09 cases per 100 person years, respectively (figure 4; table 1), with estimated treatment efficacy of 7·0% (95% CI −145 to 64·7) over 15 months. In the subgroup of 286 adherent participants who completed at least 11 doses within 16 weeks, efficacy was 22% (−138 to 74; figure 4) over 15 months. Notably, among adherent participants, there were no tuberculosis cases through 9 months (figure 4).
Adverse events related to 3HP were mostly of mild to moderate severity (appendix p 12). 67 serious adverse events, including 29 due to trauma, occurred in 65 participants. Serious adverse events occurred in 20 (5·3%) of 375 RISK11-positive participants who received 3HP (eight serious adverse events due to trauma), compared with 12 (1·6%) of 764 in RISK11-positive and 3HP-negative participants (Fisher's exact p<0·001). Among RISK11-negative participants, 33 (1·9%) of 1784 experienced serious adverse events. All but two serious adverse events were deemed unrelated to 3HP. Serious adverse events related to 3HP included one hospitalisation for seizures (unintentional isoniazid overdose) and one death of unknown cause (possibly temporally related). One death of unknown cause also occurred in an untreated RISK11-negative participant. There were 16 deaths in total, including five RISK11-positive participants receiving 3HP (three deaths due to trauma), three untreated RISK11-positive participants, and eight RISK11-negative participants.
3HP was halted in 28 (7·5%) of 375 participants, due to an adverse event of special interest (influenza-like illness or other possible hypersensitivity reaction) in 17 (4·5%), hepatotoxicity in one (0·3%), gastrointestinal symptoms in three (0·8%), and seizures in three (0·8%) participants.
RISK11 diagnostic and prognostic performance and treatment efficacy of 3HP based on the secondary endpoint definition (at least one sputum sample; appendix p 14) are described in the appendix (p 15).
Five (8·2%) of the 61 participants witih prevalent tuberculosis were resistant to isoniazid or rifampicin, or both. Two (6·7%) of the 30 participants with incident tuberculosis, both in the untreated group, were resistant to isoniazid and rifampicin. No participants were observed to have drug-resistant incident tuberculosis in the 3HP-positive group.
Discussion
Our goal was to evaluate a biomarker-targeted, community-based strategy to detect missing tuberculosis cases among people who do not seek health care, whose disease might not be detected by symptom-focused screening algorithms, and to prevent disease among those at highest risk of progression to tuberculosis. The RISK11 assay was an effective screening test for active disease in symptomatic participants, in whom performance exceeded the requirements for a triage test, but less so in asymptomatic participants. The RISK11 signature was able to predict risk for tuberculosis disease progression, in a trial population with tuberculosis incidence exceeding one case per 100 person-years, but optimal prognostic performance was limited to a 6-month horizon. While risk-targeted 3HP did not prevent tuberculosis disease over 15 months, there was some evidence of transient efficacy through 9 months among fully adherent participants.
Community-based recruitment of ambulant volunteers was not focused on individuals with known risk factors for tuberculosis, such as household contact. Individuals with recent previous history of tuberculosis (>3 years before screening) and HIV infection were excluded. Nevertheless, more than 1% of study volunteers had previously undiagnosed, microbiologically confirmed tuberculosis at enrolment, based on spontaneous expectorated rather than induced sputum samples. More than 80% of these baseline tuberculosis cases did not have any symptom compatible with tuberculosis disease and would not have been detected by a tuberculosis screening strategy that requires symptoms as the entry point to investigation. This finding is consistent with 46–79% prevalence (median 50%) of subclinical tuberculosis reported in prevalence surveys.12, 13, 14 It is not known whether subclinical tuberculosis would have progressed to symptomatic disease, spontaneously halted, or even reversed if left untreated,15, 16 nor whether subclinical disease directly contributes to M tuberculosis transmission.17 Further research is needed to determine the importance of detection, treatment, and prevention of subclinical disease for global tuberculosis control.
Although very few prevalent tuberculosis cases were symptomatic, RISK11 performance for discrimination of symptomatic prevalent tuberculosis cases from symptomatic controls exceeded the optimal TPP criteria for a triage test, while not meeting the stringent criteria for a confirmatory diagnostic test.5 A 2020 prospective observational study among symptomatic individuals who self-presented to a tuberculosis clinic assessed diagnostic accuracy of 27 transcriptomic signatures for discrimination between prevalent tuberculosis cases and controls.18 The 16-gene Zak signature, from which RISK11 was derived, did not meet the minimum WHO criteria for a triage test, but four of the 27 signatures met these criteria, suggesting that another signature might perform as well as or better than RISK11. RISK11 discrimination of asymptomatic prevalent tuberculosis cases from asymptomatic controls was modest and did not meet the minimal criteria for a triage test. These findings suggest that host blood biomarker development must consider that subclinical tuberculosis might be characterised by more heterogenous or less pronounced peripheral blood inflammatory responses than symptomatic tuberculosis, or both, which affects RNA signature performance. This finding is consistent with lower inflammatory profiles, observed by blood transcriptomic and proteomic analyses, during the subclinical phases of tuberculosis progression compared with subsequent symptomatic, active disease.19, 20 The modest performance characteristics for asymptomatic prevalent tuberculosis would limit applicability of RISK11 for biomarker-targeted, mass community screening in the South African setting, where the majority of baseline tuberculosis cases were subclinical. A host blood biomarker with good sensitivity and specificity for symptomatic tuberculosis might be most useful in countries with low to medium tuberculosis burden, where individuals with compatible symptoms might not otherwise be investigated for tuberculosis. Future diagnostic studies in symptomatic patients seeking health care should also include patients with extrapulmonary and culture-negative tuberculosis, particularly in HIV-infected cohorts, and the full spectrum of differential diagnoses that commonly mimic tuberculosis.
Prognostic performance of RISK11 for risk of progression to incident tuberculosis was poor through 15 months and did not meet the minimum TPP criteria for an incipient tuberculosis test through this prognostic horizon.4 However, good prognostic performance was observed for incident tuberculosis within 12 months of testing and performance exceeded the optimal TPP criteria for tuberculosis occurring within 6 months of testing. The positive predictive value for incident disease (1·9 vs 0·9 for RISK11 compared with IFNγ release assay, respectively) was computed from the observed tuberculosis incidence rate, which was lower than that typically used in estimations (2%).3, 6 It is not possible to determine whether the late incident tuberculosis cases occurring among RISK11-negative participants were due to reactivation or new M tuberculosis infection. We infer that a prognostic test with optimal short-term performance might be useful in identifying people who would benefit from an efficacious intervention in a low-incidence setting, in which the timing of M tuberculosis exposure is often known and subsequent exposure is unlikely.
The 3HP regimen was previously shown to be as effective as 9 months of isoniazid in preventing tuberculosis among individuals with known exposure or positive TST.21 Ethical equipoise of the intervention and control groups in this trial was based on the fact that RISK11 had been validated in selected case-control studies, which can overestimate biomarker performance, and thus risk for tuberculosis among RISK11-positive individuals needed to be tested prospectively in the field. Furthermore, although TPT is given commonly to IFNγ release assay-positive and tuberculin skin test-positive individuals, and individuals with known household exposure to a tuberculosis patient, the vast majority do not progress to tuberculosis disease if left untreated. The risk–benefit balance of 3HP preventive therapy for RISK11-positive individuals was unknown. However, we found no evidence that 3HP treatment reduced the rate of incident tuberculosis over 15 months in RISK11-positive individuals, who might be further advanced along the spectrum of tuberculosis pathogenesis.19 Interpretation of the results is limited by the wide CIs. It is also notable that no tuberculosis cases were observed in fully adherent participants through 9 months. This finding is consistent with the possibility that 3HP was sufficient to temporarily halt, but insufficient to sterilise, incipient tuberculosis, resulting in reactivation. A RISK11-targeted preventive therapy strategy for high tuberculosis transmission settings like South Africa might require a more potent therapeutic regimen than 3HP. 3HP might have been sufficient to sterilise incipient tuberculosis disease, but not to protect against tuberculosis disease resulting from reinfection after completion of the treatment course. Although it is not possible to distinguish between reactivation and reinfection tuberculosis cases in this study, we suggest that the limited time available for reinfection and subsequent progression to disease after completing 3HP makes the latter possibility less likely.
The study was subject to a number of limitations. The hybrid design required an open-label treatment group,2 with no placebo for RISK11-positive participants, so that risk for tuberculosis could also be evaluated in the control group while concealing RISK11 status from participants, site staff, and tuberculosis endpoint laboratory staff for analysis of biomarker performance. Tuberculosis case accrual during the latter stages of follow-up suggested no evidence of ascertainment bias during treatment. Extensive study simulations were done to inform the size of each group for the coprimary analyses. However, due to lower than expected prevalence of RISK11-positive status in the screened population (9·3% vs 15%), enrolment of 1139 RISK11-positive individuals required 2 years, compared with planned enrolment of 1500 RISK11-positive individuals over 1 year. As a result, fewer than expected incident tuberculosis outcomes were observed (24 vs 40 primary endpoints), which might have reduced power for both treatment efficacy and RISK11 performance analyses. Not all participants in the treatment group completed 3HP per protocol, because study drug was discontinued for suspected hypersensitivity reactions or influenza-like illnesses. However, the discontinuation rate (7·5%) was comparable to other trials of 3HP, in which study drug was discontinued in 17·9% of participants overall and in 4·9% due to an adverse event.21 The loss to follow-up rate in this trial (14·4%) was higher than expected and might reflect the challenges of retaining the study participants, in the absence of traditional tuberculosis risk factors for which surveillance is routine. However, loss to follow-up occurred predominantly after the treatment period and did not seem to have been biased by treatment factors. We note that median duration of participation was 13·9 months and thus loss to follow-up did not have major unforeseen effect on statistical power. Strengths of the study include enrolment in geographically distinct sites across South Africa that were representative of populations with different rates of IFNγ release assay positivity and tuberculosis disease, which were congruent with local rates of RISK11 positivity, although the sample size was not sufficient for analysis of signature performance or 3HP efficacy at site level. The findings broadly reflect the South African tuberculosis epidemic, but might not be directly applicable to countries with much lower tuberculosis incidence.
It is not yet known whether other parsimonious tuberculosis signatures, developed and validated like RISK11 in carefully curated case-control studies, will exhibit similar performance characteristics when prospectively tested in the field, where undiagnosed subclinical tuberculosis might pose a challenge to diagnostic performance. Head-to-head analyses of several transcriptomic tuberculosis signatures with promising diagnostic performance are currently underway on CORTIS samples and novel near-patient testing platforms are in development, which might bring cost-effective, community-based tuberculosis biomarker screening closer to implementation in the field. However, although we have shown that a strategy of biomarker-guided tuberculosis preventive therapy is feasible, the optimal preventive therapy regimen for use in such a strategy remains elusive.
Data sharing
Deidentified RISK11 signature scores and primary tuberculosis endpoint data from all participants will be available with publication. The dataset is deposited in Zivahub (https://doi.org/10.25375/uct.13573337.v1), an open access data repository hosted by the University of Cape Town's institutional data repository powered by Figshare for Institutions.
Supplementary Material
Supplementary appendix
Acknowledgments
The trial was funded by the Bill & Melinda Gates Foundation (OPP1116632, OPP1137034) and the Strategic Health Innovation Partnerships Unit of the South African Medical Research Council with funds received from the South African Department of Science and Technology. Rifapentine was donated by the manufacturer (Sanofi). The authors thank the members of the data and safety monitoring board and the trial steering committee.
Contributors
TJS, AF-G, AP-N, SS, GW, KN, GC, and MH designed the study. CI, WB, AH, STM, RH-M, MT, GW, KN, and GC recruited and evaluated participants. TJS, AP-N, SKM, SCM, KH, MM, NB, ME, LJ, and RR collected and analysed laboratory data. AF-G, and BB accessed and verified the data. TJS, AF-G, AP-N, HM, BB, TS, RGW, and MH analysed data and interpreted results. KH, CH, and MK provided operational support. TJS, AF-G, HM, and MH drafted the Article. All authors had full access to the data, and reviewed, revised and gave final approval of the Article before submission.
The CORTIS-01 Study Team
Kesenogile Baepanye, Tshepiso Baepanye, Ken Clarke, Marelize Collignon, Audrey Dlamini, Candice Eyre, Tebogo Feni, Moogo Fikizolo, Phinda Galane, Thelma Goliath, Alia Gangat, Shirley Malefo-Grootboom, Elba Janse van Rensburg, Bonita Janse van Rensburg, Sophy Kekana, Marietjie Zietsman, Adrianne Kock, Israel Kunene, Aneessa Lakhi, Nondumiso Langa, Hilda Ledwaba, Marillyn Luphoko, Immaculate Mabasa, Dorah Mabe, Nkosinathi Mabuza, Molly Majola, Mantai Makhetha, Mpho Makoanyane, Blossom Makhubalo, Vernon Malay, Juanita Market, Selvy Matshego, Nontsikelelo Mbipa, Tsiamo Mmotsa, Sylvester Modipa, Samuel Mopati, Palesa Moswegu, Primrose Mothaga, Dorothy Muller, Grace Nchwe, Maryna Nel, Lindiwe Nhlangulela, Bantubonke Ntamo, Lawerence Ntoahae, Tedrius Ntshauba, Nomsa Sanyaka, Letlhogonolo Seabela, Pearl Selepe, Melissa Senne, MG Serake, Maria Thlapi, Vincent Tshikovhi, Lebogang Tswaile, Amanda van Aswegen, Lungile Mbata, Constance Takavamanya, Pedro Pinho, John Mdlulu, Marthinette Taljaard, Naydene Slabbert, Sharfuddin Sayed, Tanya Nielson, Melissa Senne, Ni Ni Sein, Lungile Mbata (The Aurum Institute); Dhineshree Govender, Tilagavathy Chinappa, Mbali Ignatia Zulu, Nonhle Bridgette Maphanga, Senzo Ralph Hlathi, Goodness Khanyisile Gumede, Thandiwe Yvonne Shezi, Jabulisiwe Lethabo Maphanga, Zandile Patrica Jali, Thobelani Cwele, Nonhlanhla Zanele Elsie Gwamanda, Celaphiwe Dlamini, Zibuyile Phindile Penlee Sing, Ntombozuko Gloria Ntanjana, Sphelele Simo Nzimande, Siyabonga Mbatha, Bhavna Maharaj, Atika Moosa, Cara-Mia Corris (Centre for the AIDS Programme of Research in South Africa); Fazlin Kafaar, Marwou De Kock, Hennie Geldenhuys, Angelique Kany Kany Luabeya, Justin Shenje, Natasja Botes, Susan Rossouw, Hadn Africa, Bongani Diamond, Samentra Braaf, Sonia Stryers, Alida Carstens, Ruwiyda Jansen, Simbarashe Mabwe, Roxane Herling, Ashley Veldsman, Lebohgang Makhete, Marcia Steyn, Sivuyile Buhlungu, Margareth Erasmus, Ilse Davids, Patiswa Plaatjie, Alessandro Companie, Frances Ratangee, Helen Veldtsman, Christel Petersen, Charmaine Abrahams, Miriam Moses, Xoliswa Kelepu, Yolande Gregg, Liticia Swanepoel, Nomsitho Magawu, Nompumelelo Cetywayo, Lauren Mactavie, Habibullah Valley, Elizabeth Filander, Nambitha Nqakala, Angelique Mouton, Fajwa Opperman, Elma Van Rooyen, Petrus Tyambetyu (South African Tuberculosis Vaccine Initiative, University of Cape Town); Elizna Maasdorp, Justine Khoury, Belinda Kriel, Bronwyn Smith, Liesel Muller, Susanne Tonsing, Andre Loxton, Andriette Hiemstra, Petri Ahlers, Marika Flinn (DST/NRF Centre of Excellence for Biomedical TB Research and SAMRC Centre for TB Research, Stellenbosch University); and Eva Chung, Michelle Chung, Alicia Sato (Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Research Center)
Declaration of interests
TJS has a patent of the RISK11 signature pending and reports grants from the Bill and Melinda Gates Foundation and South African Medical Research Council. KN reports grants from CAPRISA. GW reports a patent (PCT/IB2019/052043) pending to University of Cape Town, Stellenbosch University, Max-Planck-Gesellschaft Zur Foerderung Der Wissenschaften EV, Seattle Children's Hospital Doing Business as Seattle Children's Research Institute, and UK Research and Innovation. GC reports grants from the Bill & Melinda Gates Foundation. AP-N has a patent of the RISK11 signature pending and reports grants from the Bill & Melinda Gates Foundation and the South African Medical Research Council. MH reports grants from the Bill & Melinda Gates Foundation and the South African Medical Research Council. | Oral | DrugAdministrationRoute | CC BY | 33508224 | 20,168,180 | 2021-03 |
What was the dosage of drug 'ISONIAZID'? | Biomarker-guided tuberculosis preventive therapy (CORTIS): a randomised controlled trial.
Targeted preventive therapy for individuals at highest risk of incident tuberculosis might impact the epidemic by interrupting transmission. We tested performance of a transcriptomic signature of tuberculosis (RISK11) and efficacy of signature-guided preventive therapy in parallel, using a hybrid three-group study design.
Adult volunteers aged 18-59 years were recruited at five geographically distinct communities in South Africa. Whole blood was sampled for RISK11 by quantitative RT-PCR assay from eligible volunteers without HIV, recent previous tuberculosis (ie, <3 years before screening), or comorbidities at screening. RISK11-positive participants were block randomised (1:2; block size 15) to once-weekly, directly-observed, open-label isoniazid and rifapentine for 12 weeks (ie, RISK11 positive and 3HP positive), or no treatment (ie, RISK11 positive and 3HP negative). A subset of eligible RISK11-negative volunteers were randomly assigned to no treatment (ie, RISK11 negative and 3HP negative). Diagnostic discrimination of prevalent tuberculosis was tested in all participants at baseline. Thereafter, prognostic discrimination of incident tuberculosis was tested in the untreated RISK11-positive versus RISK11-negative groups, and treatment efficacy in the 3HP-treated versus untreated RISK11-positive groups, during active surveillance through 15 months. The primary endpoint was microbiologically confirmed pulmonary tuberculosis. The primary outcome measures were risk ratio [RR] for tuberculosis of RISK11-positive to RISK11-negative participants, and treatment efficacy. This trial is registered with ClinicalTrials.gov, NCT02735590.
20 207 volunteers were screened, and 2923 participants were enrolled, including RISK11-positive participants randomly assigned to 3HP (n=375) or no 3HP (n=764), and 1784 RISK11-negative participants. Cumulative probability of prevalent or incident tuberculosis disease was 0·066 (95% CI 0·049 to 0·084) in RISK11-positive (3HP negative) participants and 0·018 (0·011 to 0·025) in RISK11-negative participants (RR 3·69, 95% CI 2·25-6·05) over 15 months. Tuberculosis prevalence was 47 (4·1%) of 1139 versus 14 (0·78%) of 1984 in RISK11-positive compared with RISK11-negative participants, respectively (diagnostic RR 5·13, 95% CI 2·93 to 9·43). Tuberculosis incidence over 15 months was 2·09 (95% CI 0·97 to 3·19) vs 0·80 (0·30 to 1·30) per 100 person years in RISK11-positive (3HP-negative) participants compared with RISK11-negative participants (cumulative incidence ratio 2·6, 95% CI 1·2 to 5·9). Serious adverse events related to 3HP included one hospitalisation for seizures (unintentional isoniazid overdose) and one death of unknown cause (possibly temporally related). Tuberculosis incidence over 15 months was 1·94 (95% CI 0·35 to 3·50) versus 2·09 (95% CI 0·97 to 3·19) per 100 person-years in 3HP-treated RISK11-positive participants compared with untreated RISK11-positive participants (efficacy 7·0%, 95% CI -145 to 65).
The RISK11 signature discriminated between individuals with prevalent tuberculosis, or progression to incident tuberculosis, and individuals who remained healthy, but provision of 3HP to signature-positive individuals after exclusion of baseline disease did not reduce progression to tuberculosis over 15 months.
Bill and Melinda Gates Foundation, South African Medical Research Council.
Introduction
Large-scale prevention of progression from Mycobacterium tuberculosis infection to tuberculosis disease is key to achieving WHO End TB Strategy targets, yet tuberculin skin tests (TST) and interferon (IFN) γ release assays have poor specificity for incident tuberculosis.1 A biomarker-targeted prevention strategy using a highly specific correlate of risk (COR) for incident tuberculosis, in tandem with effective short-course tuberculosis preventive therapy (TPT),2 might impact the epidemic by preventing incident tuberculosis disease before transmission.3 Modelling suggests a three-times reduction in burden of TPT if targeted by COR, compared with IFNγ release assays and TST.4 Furthermore, because active tuberculosis disease should be excluded before starting TPT, additional utility of the prognostic COR as a screening (triage) test to identify undiagnosed tuberculosis disease would allow earlier curative treatment. WHO and FIND have developed target product profiles (TPP) for triage tests for tuberculosis (optimal and minimum sensitivity of >95% and >90%, and specificity of >80% and >70%, respectively),5 and incipient tuberculosis tests (minimum sensitivity and specificity of 75% and 75%, and optimal sensitivity and specificity of 90% and 90%, respectively).6
Research in context
Evidence before this study
Host blood RNA signatures have potential as tuberculosis triage or diagnostic tests, and as predictive tests to target tuberculosis preventive therapy. We searched MEDLINE, Scopus, Web of Science, and EBSCO libraries for publications between Jan 1, 2005, and May 31, 2020, using the search terms “Tuberculosis” OR “TB” OR “Mycobacterium tuberculosis” OR “MTB” AND “diagnosis” OR “diagnostic” OR “detect” OR “predic”OR “prognosis” OR “prognostic” OR “screen” AND “Blood Biomarker” OR “blood biomarkers” OR “bio-signature” OR “gene expression” OR “genetic transcription” OR “host blood” OR “immune marker” OR “immunologic marker” OR “Ribonucleic Acid” OR “RNA” OR “signature” OR “surrogate endpoint” OR “surrogate marker” OR “transcriptome” OR “transcriptomic” AND “Area under curve” OR “AUC” OR “receiver operating characteristic” OR “ROC” OR “Accuracy” OR “Performance” OR “sensitivity” OR “specificity”. Studies comparing blood RNA signatures in individuals with tuberculosis versus Mycobacterium tuberculosis-uninfected controls, individuals with other respiratory diseases, or with M tuberculosis infection and using a microbiological reference standard of either sputum M tuberculosis culture, Xpert MTB/RIF, or smear microscopy for tuberculosis diagnosis, were included.
28 studies reported evaluation of 32 host blood RNA signatures for diagnosis or prediction of progression to tuberculosis disease in 83 cohorts. Only two studies prospectively tested performance of an RNA signature in all evaluable participants; the remainder used a case-control design. Multiple studies have tested tuberculosis preventive therapy in people with M tuberculosis latent tuberculosis infection. No studies have tested efficacy of tuberculosis preventive therapy to avert disease in RNA signature-positive people.
Added value of this study
This large randomised, controlled trial in five South African communities prospectively tested diagnostic and prognostic performance of an RNA signature (RISK11) in all evaluable participants, and estimated efficacy of tuberculosis preventive therapy to avert disease in RNA signature-positive people. More than 1% of HIV-uninfected community volunteers had previously undiagnosed, microbiologically confirmed tuberculosis at screening, more than 80% of which was asymptomatic. RISK11 showed moderate performance for tuberculosis triage, but good performance for diagnosis of symptomatic tuberculosis, and for short-term prediction of incident tuberculosis. 3 months of once-weekly, high-dose isoniazid and rifapentine (3HP) did not reduce incident disease in RISK11-positive individuals over 15 months of follow-up.
Implications of all the available evidence
Host blood biomarker development must consider that subclinical tuberculosis might be characterised by more heterogenous, or less pronounced blood inflammatory responses than symptomatic tuberculosis, or both, which will affect RNA signature performance. RISK11 might be better suited to screening of symptomatic individuals with possible tuberculosis than for mass community-based screening. RISK11 can identify those at highest risk for short-term progression to disease, but a more potent regimen than 3HP might be needed to prevent tuberculosis in RISK11-positive individuals.
We previously developed a 16-gene transcriptomic signature by whole blood RNA sequencing for identification of individuals at high risk of developing tuberculosis (the Zak16 signature).7, 8 Measurement of Zak16 was adapted to quantitative RT-PCR (RT-qPCR), and predictive ability for incident tuberculosis was validated in an independent longitudinal cohort of household contacts of tuberculosis patients.8 We reduced this signature to 11 genes (RISK11) with equivalent performance,9, 10 to allow testing in 96-well PCR format. Zak16 and RISK11 also did well as non-sputum screening tests for prevalent, active tuberculosis in case-control studies, measured by RNA sequencing, microarray,7, 8 or microfluidic RT-qPCR.9, 10 In a 2020 systematic review and patient-level pooled meta-analysis of 17 transcriptomic signatures for prognosis of incident tuberculosis, Zak16 was among eight signatures that achieved a positive predictive value above the WHO TPP benchmark for incipient tuberculosis tests.11 Since case-control studies might overestimate performance characteristics, testing in unselected populations is needed.
We report on a randomised controlled trial (CORTIS; NCT02735590), which prospectively measured diagnostic and prognostic performance of RISK11 for triage of prevalent and prediction of incident tuberculosis in South African adults; and, in parallel, estimated efficacy of short-course TPT to avert incident disease in RISK11-positive individuals.
Methods
Study design
This randomised controlled trial used a hybrid treatment selection, three-group study design to evaluate efficacy of the intervention and, in parallel, performance of the biomarker used to allocate that intervention (figure 1).2 The coprimary aims were to test, over 15 months, whether RISK11 status differentiates between people with and without cumulative prevalent or incident tuberculosis; and whether preventive therapy (weekly high-dose isoniazid and rifapentine for 12 weeks [3HP]) reduces tuberculosis incidence among RISK11-positive people compared with active surveillance only. RISK11 performance to detect prevalent tuberculosis was evaluated in all groups at baseline. RISK11 performance to predict incident tuberculosis was evaluated in the untreated RISK11-positive and RISK11-negative groups, and treatment efficacy was estimated from the 3HP treated and untreated RISK11-positive groups, after omitting participants with baseline tuberculosis. Efficiency of the hybrid study design was maximised by using the RISK11-positive and 3HP-negative group to evaluate both biomarker performance and treatment efficacy.Figure 1 Study design
The prevalence of RISK11 positivity was not precisely known in the study population; therefore, the number of individuals to be screened and the randomisation of RISK11-negative participants to enrolment was monitored and adjusted adaptively to ensure concurrent enrolment of the target number of RISK11-positive and RISK11-negative participants, per protocol specifications. The study used a three-group design to evaluate efficacy of the intervention and, in parallel, performance of the biomarker used to allocate that intervention. Diagnostic performance for differentiation of prevalent tuberculosis was tested in all three groups at baseline; prognostic performance for differentiation of incident tuberculosis over 15 months was tested in the two untreated groups (untreated RISK11 positive and untreated RISK11 negative); and treatment efficacy of 3HP over 15 months was tested in the two RISK11-positive groups (treated and untreated RISK11 positive). *Participants evaluated for eligibility at screening and enrolment. †Groups randomly assigned in blocks to ensure concurrent enrolment.
Routine implementation of TPT requires that patients are screened to exclude prevalent tuberculosis before TPT is provided to prevent incident disease. Therefore, because risk for prevalent and incident tuberculosis by RISK11 status must be understood before efficacy of preventive therapy against incident tuberculosis in RISK11-positive people can be interpreted, these secondary analyses are presented before the primary analysis of treatment efficacy.
The trial protocol (appendix p 21) was approved by the South African Health Products Regulatory Agency (20160305) by the Institutional Human Ethics Committees of participating sites; and was registered on ClinicalTrials.gov (NCT02735590). All participants provided written informed consent in their language of choice.
Participants
Adult volunteers living in tuberculosis-endemic communities in South Africa were recruited at five sites (South African Tuberculosis Vaccine Initiative, Worcester; Immunology Research Group, Stellenbosch University, Ravensmead; Aurum Institute, Klerksdorp and Rustenberg; and Centre for the AIDS Programme of Research in South Africa, Durban). Community-based recruitment was by word-of-mouth, house-to-house visits, and liaison with non-governmental organisations. Recruitment did not target groups at high risk of tuberculosis, such as household contacts. Eligible participants were aged between 18 years and 59 years, HIV-negative, without a history of tuberculosis disease in the last 3 years or preselected comorbidities (appendix p 8).
Screening
Venous blood was collected in PAXgene RNA tubes from all potentially eligible people at screening, frozen at −20°C, and shipped weekly to the South African Tuberculosis Vaccine Initiative Immunology Laboratory for RISK11 testing by qRT-PCR assay. Participants with a RISK11 score of at least 60% were classified a priori as RISK11 positive and less than 60% as RISK11 negative. This 60% threshold was the optimal point at which sensitivity and specificity for prognosis of incident tuberculosis were balanced in case-control studies.2 Samples with failed reference primer-probe reactions, with marked deviation in internal positive control sample from historical runs, or more than 30% failed interferon-stimulated genes primer-probe reactions (see quality control criteria and analysis script in Bitbucket instance) were classified as indeterminate. Per-participant qualitative results (RISK11 positive and RISK11 negative) were provided to the Triclinium Clinical Development (TCD) Data Centre for participant randomisation (see appendix pp 2–3).
Randomisation and masking
Assignment to study group was managed by an unmasked randomisation team from the TCD Data Centre, based on RISK11 status. RISK11-positive volunteers were randomly assigned (1:2; block size 15) to either open-label 3HP (3HP-positive group), or active tuberculosis surveillance without 3HP (3HP-negative group), in accordance with a randomisation schedule generated using SAS, version 9.4. RISK11-negative volunteers were concurrently randomly assigned either to active tuberculosis surveillance (3HP-negative group) or to non-participation, to enrich the study population for RISK11-positive participants.
Study group allocation was revealed to site staff after enrolment of eligible participants within 28 days of screening. The 3HP-negative group was double-blinded to RISK11 status, but unblinded to treatment allocation; the 3HP-positive group was unblinded to both RISK11-positive status and treatment allocation (figure 1). RISK11-positive participants randomly assigned to active surveillance did not receive a placebo, to maintain blinding of participants and study team members to RISK11 status.
Procedures
Target enrolment was maximally 3200 participants (1500 RISK11 positive and 1700 RISK11 negative). The randomisation ratio for RISK11-negative volunteers was adapted to ensure concurrent enrolment of the recruitment target. Adaptations occurred at intervals, informed by 3-monthly operational monitoring reports based on enrolment rate, RISK11-positive and RISK11-negative prevalence, and tuberculosis case accrual blinded to RISK11 status (appendix p 7).
Enrolment procedures included phlebotomy for IFNγ release assays (QuantiFERON TB Gold-Plus, Qiagen), tuberculosis symptom screen (a positive tuberculosis symptom screen included one or more symptoms of persistent unexplained cough, fever, night sweats, weight loss, or any haemoptysis), and collection of two spontaneous expectorated sputum samples for Xpert MTB/RIF assay (Cepheid) from all sputum-productive participants, regardless of symptoms.
All participants attended up to seven study visits, including four study site visits at months 3, 6, 12, and 15 (end of study), and three telephonic contact or field visits at months 1, 2, and 9. HIV testing was repeated at months 6 and 12.
Participants in the 3HP group received open-label, high-dose isoniazid (15 mg/kg; maximum dose 900 mg) with pyridoxine supplementation (25 mg) and rifapentine based on body weight (>32–50 kg, 750 mg; >50 kg, 900 mg), given weekly as directly observed oral doses, ideally with food, over 12 weeks. Completion of 3HP treatment was defined as receipt of 11 doses within 16 weeks (appendix p 3).
Outcomes
The two primary outcome measures were RISK11-positive to RISK11-negative risk ratio (RR) for prevalent or incident tuberculosis disease, and 3HP treatment efficacy through 15 months. Diagnostic performance for prevalent tuberculosis was evaluated on the presence of tuberculosis at the enrolment visit within the ITT cohort.
Participants in the 3HP group had each dose directly observed by study staff, and attended clinic for evaluation of solicited adverse events and possible adverse events of special interest at weeks 1–11. Solicited adverse events included gastrointestinal signs and symptoms suggestive of hepatotoxicity, such as nausea, vomiting, and jaundice. Possible hypersensitivity reactions, including influenza-like illness, were reported as adverse events of special interest. Safety events meeting the definition for a serious adverse event, whether deemed related or unrelated to study drug, were reported for both all participants through end of study.
Statistical analysis
The intention-to-treat (ITT) cohort included all enrolled participants who completed investigation for tuberculosis endpoints at baseline. The modified intention-to-treat (mITT) cohort included all participants in the ITT population who completed at least one post-baseline tuberculosis endpoint investigation and omitted participants with endpoint-defined tuberculosis disease at baseline (prevalent tuberculosis).
The diagnostic RR was estimated as a proportion of participants with tuberculosis disease among RISK11-positive divided by RISK11-negative participants. Prognostic performance for incident tuberculosis after enrolment was evaluated among 3HP-negative participants within the mITT cohort (ie, excluding participants with tuberculosis at baseline). Prognostic RR was estimated as the cumulative incidence through 15 months for RISK11-positive divided by RISK11-negative participants. The primary RR was an estimate of the probability of having prevalent tuberculosis or developing incident tuberculosis among RISK11-positive divided by RISK11-negative participants; this combined probability of prevalent and incident tuberculosis was computed for each group as the probability of prevalent tuberculosis plus the probability of incident tuberculosis through 15 months (conditioned on not having prevalent tuberculosis). Efficacy of 3HP preventive therapy to reduce the rate of incident tuberculosis disease compared with the untreated RISK11-positive participants was also evaluated in the mITT population. Treatment efficacy was estimated as one minus the cumulative incidence of RISK11-positive and 3HP-positive participants divided by RISK11-positive and 3HP-negative participants through 15 months. A per-protocol analysis of treatment efficacy was done and excluded RISK11-positive and 3HP-positive participants that received less than 11 of the 12 weekly doses of 3HP.
For statistical efficiency, a random subset of RISK11-negative participants were enrolled, therefore creating an ITT cohort artificially enriched with RISK11-positive participants. Therefore, unless stated otherwise, all analyses were adjusted so that results reflected the screened population. Secondary performance metrics such as sensitivity and specificity were estimated using standard formulas with binary endpoints; a percentile bootstrap with 20 000 samples was used to estimate 95% CIs. For descriptive analyses (Table 1, Table 2), rank-based Wilcoxon rank-sum tests were used to compare continuous variables in RISK11-positive versus RISK11-negative groups. Fisher's exact test was used to compare binary readouts; p values in Table 1, Table 2 were not adjusted for multiple comparisons. The prespecified statistical analysis plan is included in the appendix (p 82) and contains detailed description of the statistical methods.Table 1 Baseline characteristics and primary tuberculosis endpoints by group
Total (n=2923) RISK11 positive and 3HP positive (n=375) RISK11 positive and 3HP negative (n=764) RISK11 negative (n=1784) RISK11 positive vs RISK11 negative, p value*
Sex
Female 1585 (54·2%) 213 (56·8%) 469 (61·4%) 903 (50·6%) <0·001
Male 1338 (45·8%) 162 (43·2%) 295 (38·6%) 881 (49·4%) ..
Age, years 28·5 (9·0) 28·8 (9·5) 28·4 (9·2) 28·4 (8·7) 0·541
Race or ethnicity
Asian 4 (0·1%) 0 1 (0·1%) 3 (0·2%) 0·567
Black African 1947 (66·6%) 227 (60·5%) 477 (62·4%) 1243 (69·7%) <0·001
White 4 (0·1%) 0 1 (0·1%) 3 (0·2%) 0·567
Mixed race 968 (33·1%) 148 (39·5%) 285 (37·3%) 535 (30·0%) <0·001
Body-mass index, kg/m2 24·6 (7·7) 24·1 (6·3) 24·4 (6·1) 24·9 (8·6) 0·354
Previous tuberculosis 230 (7·9%) 36 (9·6%) 75 (9·8%) 119 (6·7%) 0·003
Smoking 1478 (50·6%) 203 (54·1%) 391 (51·2%) 884 (49·6%) 0·170
Family tuberculosis history 462 (15·8%) 66 (17·6%) 110 (14·4%) 286 (16·0%) 0·675
Interferon γ release assay positive 1895 (64·8%) 250 (66·7%) 528 (69·1%) 1117 (62·6%) <0·001
Follow-up, months 15 (9·4–15·0) 15 (11·1–15·0) 15 (9·1–15·0) 13·6 (9·4–15·0) 0·056
Prevalent tuberculosis, n (probability, 95% CI) 61 (1·1%, 0·77–1·6)† 47 (4·1%, 3·1–5·4)‡ 47 (4·1%, 3·1–5·4)§ 14 (0·78%, 0·47–1·3) NA
Incident tuberculosis, n (cases per 100 person years, 95% CI) 24 (1·05, 0·59–1·5)§ 6 (1·9, 0·35–3·5) 14 (2·09, 0·97–3·19) 10 (0·80, 0·30–1·30) NA
Cumulative tuberculosis, n (probability, 95% CI)¶ 85 (0·022, 0·016–0·028)† 61 (0·066, 0·049–0·084)‖** 61 (0·066, 0·049–0·084)** 24 (0·018, 0·011–0·026) NA
Data are n (%), mean (SD), or median (IQR), unless stated otherwise. Secondary tuberculosis endpoints by group are in the appendix (p 13). NA=not applicable.
* For continuous data, p values from Wilcoxon rank sum test. For categorical data, p values from Fischer's exact test.
† Overall rate estimates are weighted combinations of the enrolled participants to reflect the screened population.
‡ Overall incidence and cumulative tuberculosis excludes RISK11-positive and 3HP-positive incident cases.
§ Prevalent tuberculosis among RISK11 positive was assessed by combining the 3HP-negative and 3HP-positive groups. Value is repeated for RISK11 positive and 3HP positive, and RISK11 positive and 3HP negative.
¶ Probability of observing prevalent or incident tuberculosis over 15 months.
‖ Probability of prevalent or incident tuberculosis not estimated for RISK11-positive and 3HP-positive because it would combine data from before and after 3HP treatment and is therefore potentially misleading.
** Estimate for RISK11 positive includes 3HP-positive prevalent cases and 3HP-negative prevalent and incident cases. Value is repeated for RISK11 positive and 3HP positive, and RISK11 positive and 3HP negative.
Table 2 Performance of RISK11 and IGRA for prevalent and incident tuberculosis
Prevalent tuberculosis (ITT cohort) Incident tuberculosis (mITT cohort)*
RISK11 (60)† RISK11 (26)† IGRA RISK11 (60)† RISK11 (26)† IGRA
Risk ratio 5·13 (2·93 to 9·43) 7·39 (3·46 to 25·69) 4·43 (1·93 to 14·18) 2·61 (1·15 to 5·94) 2·67 (1·04 to 8·66) 2·83 (0·95 to 99·79)
Biomarker prevalence 9·2% (9·2 to 9·2) 25·8% (24·1 to 27·4) 63·4% (61·3 to 65·4) 9·0% (9·0 to 9·0) 25·3% (23·7 to 26·9) 63·2% (61·1 to 65·3)
AUC‡ 0·77 (0·68 to 0·86) .. 0·66 (0·58 to 0·73) 0·63 (0·47 to 0·80) .. 0·67 (0·54 to 0·79)
Sensitivity 34·9% (23·7 to 52·2) 72·1% (54·5 to 90·2) 88·7% (77·1 to 96·4) 25·0% (12·7 to 45·9) 47·5% (25·9 to 75·0) 83·2% (61·9 to 100·0)
Specificity 91·0% (90·9 to 91·1) 74·7% (73·1 to 76·4) 36·9% (34·9 to 39·0) 91·1% (91·0 to 91·2) 74·9% (73·2 to 76·5) 37·0% (34·9 to 39·1)
PPV§ 4·1% (3·0 to 5·4) 3·1% (2·0 to 4·3) 1·5% (1·0 to 2·2) 1·9% (0·9 to 3·0) 1·3% (0·6 to 2·1) 0·9% (0·5 to 1·4)
PPV (2% incidence)¶ .. .. .. 6·7% (3·5 to 11·8) 4·6% (2·5 to 7·1) 3·3% (2·5 to 3·9)
NPV§ 99·2% (98·8 to 99·6) 99·6% (99·2 to 99·9) 99·7% (99·3 to 99·9) 99·4% (99·0 to 99·8) 99·5% (99·1 to 99·9) 99·7% (99·2 to 100·0)
NPV (2% incidence)¶ .. .. .. 97·9% (97·6 to 98·5) 98·2% (97·5 to 99·2) 98·8% (97·4 to 100·0)
NNS or NNT‖ 29·9 (21·8 to 46·6) 37·8 (25·5 to 65·7) 83·1 (53·2 to 179·8) 75·1 (40·4 to 277·5) 123·8 (47·2 to 834·1) 168 (−440 to 1059)
Data are risk ratio (95 %CI), % (95% CI), AUC (95% CI), or NNS or NNT (95% CI). ITT=intention to treat. mITT=modified intention-to-treat. IGRA=interferon γ release assay. AUC=area under the receiver operating characteristic curve. PPV=positive predictive value. NPV=negative predictive value. NNS=number needed to screen. NNT=number needed to treat.
* Computed over 15-month prognostic window. Performance of RISK11 and IGRA for incident tuberculosis over 6-month and 12-month prognostic windows is in the appendix (p 16).
† RISK11 score threshold at 60% or 26%.
‡ AUC is computed across all score thresholds and value is presented under RISK11 (60).
§ Computed using the prevalence and incidence rates in the trial population as appropriate.
¶ Computed assuming 2% annual incidence of tuberculosis in the population.
‖ NNS for prevalent tuberculosis; NNT for incident tuberculosis. Performance of RISK11 and IGRA for prevalent and incident tuberculosis based on secondary endpoint (≥1 sample+) is in the appendix (p 15).
The study was designed to have 90% power to reject the null hypothesis of a RISK11-positive and RISK11-negative cumulative risk ratio less than 2 with one-sided alpha of 0·025. For treatment efficacy there was 80% power to reject the null hypothesis of efficacy less than 20%, with one-sided alpha of 0·05 and under the alternative design hypothesis that efficacy was 80%. To compute statistical power for these aims, a stochastic simulation of the trial was constructed, based on which we expected to observe 33 tuberculosis disease endpoints among 1500 RISK11-positive participants and seven tuberculosis disease endpoints among 1700 RISK11-negative participants (appendix p 6).
Role of the funding source
The trial was funded by the Bill & Melinda Gates Foundation (OPP1116632, OPP1137034) and the Strategic Health Innovation Partnerships Unit of the South African Medical Research Council, with funds received from the South African Department of Science and Technology. The Gates Foundation contributed to the study design. The regulatory sponsor was the University of Cape Town. Rifapentine (PRIFTIN) was donated by the manufacturer (Sanofi), who had no role in the design, implementation, analysis, or reporting of the trial. All authors had access to all the data reported in the study. The corresponding author had final responsibility for the decision to submit for publication.
Results
Between Sept 20, 2016, and Oct 19, 2018, 20 207 volunteers consented to participation; 16 248 met inclusion criteria at screening and 15 777 with a RISK11 result were potentially eligible for enrolment (figure 2). Of the 20 207 adults assessed for eligibility, common reasons for exclusion included HIV infection (1246 [6·1%]) and comorbid conditions (1369 [6·8%]; appendix p 8). 2923 eligible participants were enrolled after randomisation (1784 [61·0%] RISK11 negative and 1139 [39·0%] RISK11 positive; table 1).Figure 2 Trial profile
ITT=intention to treat. mITT=modified intention to treat. LTFU=lost to follow-up. PP=per protocol analysis. *585 participants did not complete the trial for reasons including: 53 (9%) pregnancies, 22 (4%) investigator withdrawals, 46 (8%) consent withdrawals, 26 (4%) HIV infections, 422 (72%) LTFU, and 16 (3%) deaths.
Participants were enrolled at five geographically diverse sites across South Africa (appendix pp 9–11). Among participants with a RISK11 result, 1434 (9·3%) of 15 494 were RISK11 positive, with the proportion ranging from 6·2% to 13·0% across the five sites. RISK11-positive participants were randomly asigned either to receive treatment (375 [32·9%] RISK11 positive and 3HP positive) or undergo observation without treatment (764 [67·1%] RISK11 positive and 3HP negative).
There were no significant differences in smoking history, family history of tuberculosis, or febrile illness between RISK11-positive and RISK11-negative participants (table 1). A higher proportion of RISK11-positive (75 [9·8%] of 364) than RISK11-negative (119 [6·7%] of 1784) participants reported previous tuberculosis disease (p=0·003). Compared with RISK11 negative participants, a greater proportion of RISK11-positive participants were female and mixed race (p<0·001; table 1).
Median duration of follow-up for incident tuberculosis was 13·9 months (IQR 9·0–15·0) and 1879 (66%) of 2500 3HP-negative mITT participants attended at least six scheduled visits. 1416 (49%) of 2838 participants were followed up for 15 months and 2160 (75%) of 2838 participants were followed up for at least 9 months. 585 (21%) of 2838 participants did not complete the study because of withdrawal, death, or loss to follow-up (figure 2; table 1).
Among 91 participants with tuberculosis who reached the primary endpoint, 61 were diagnosed with prevalent tuberculosis at baseline (47 RISK11 positive and 14 RISK11 negative; table 1; appendix p 13). Prevalence of tuberculosis in RISK11-positive and RISK11-negative participants was 4·1% (95% CI 3·1–5·4) and 0·78% (0·5–1·3), respectively (figure 3). Thereafter, 24 participants in the untreated group were diagnosed with incident tuberculosis disease (14 RISK11 positive and ten RISK11 negative; table 1; appendix p 13) with overall incidence of 1·05 cases (95% CI 0·59–1·5) per 100 person-years.Figure 3 RISK11 detection of combined prevalent and incident tuberculosis and diagnostic performance
(A) Prevalence of tuberculosis in RISK11-positive (47 cases,) and RISK11-negative (14 cases, red bar) participants at trial enrolment. Error bars depict 95% CI. Cumulative incidence probability of tuberculosis in RISK11-positive (14 cases, blue line) or RISK11-negative (10 cases, red line) mITT participants during follow-up. Shaded areas represent 95% CI. (B) Ratio of RISK11-positive versus RISK11 negative cumulative incidence probability of observing prevalent or incident tuberculosis disease, in the ITT population of the observation group. (C) RISK11 signature scores (each dot represents a participant) measured at screening in trial participants, stratified on tuberculosis diagnosis. Boxes depict IQR, midline represents the median, and whiskers indicate range among enrolled participants. (D) RISK11 signature scores measured at screening in prevalent tuberculosis cases with or without any tuberculosis symptoms, in incident tuberculosis cases or those who did not have a tuberculosis diagnosis. The enrolled population, not the screened population, is represented in (C) and (D), because a large fraction of RISK11-negative participants were not enrolled by design. (E) ROC curves depicting RISK11 diagnostic performance for prevalent tuberculosis in the ITT population, for prevalent tuberculosis among individuals with no symptoms of tuberculosis (asymptomatic) and among individuals with at least one symptom consistent with tuberculosis disease (symptomatic). Shaded areas represent the 95% CI. The grey and black dots indicate the minimum and optimal criteria, respectively, set out in the WHO target product profile for a triage test. The empty dot indicates the criteria set out in the WHO target product profile for a confirmatory diagnostic test. TRP=true positive rate. ITT=intention to treat. FPR=false positive rate. AUC=area under the receiver operating characteristic curve.
In the primary analysis of biomarker performance for cumulative tuberculosis, cumulative probability of observing prevalent or incident tuberculosis disease in the ITT population was 0·066 (95% CI 0·049–0·084) in RISK11-positive participants and 0·018 (0·011–0·025) in RISK11-negative participants, with a risk ratio of 3·69 (95% CI 2·25–6·05) over 15 months (figure 3).
A wide range of RISK11 scores was observed, irrespective of tuberculosis outcome (figure 3). Among enrolled participants, those who remained tuberculosis free (controls) had significantly lower RISK11 scores (24·2%, IQR 8·2–75·3) than those with prevalent or incident tuberculosis disease (76·7%, 36·6–94·4; Wilcoxon rank-sum test p<0·0001; figure 3).
In the secondary analysis of biomarker performance for prevalent tuberculosis, using the prespecified RISK11 test threshold (60%) there was 5·13-times (95% CI 3·01–10·69) increased risk of prevalent tuberculosis disease at baseline in RISK11-positive versus RISK11-negative participants, with sensitivity of 35% (95% CI 24–52) and specificity of 91% (95% CI 91–91; table 2). The receiver operating characteristic (ROC) analysis (figure 3) showed that a RISK11 threshold of 26% provided sensitivity of 72% (95% CI 54–90) and specificity of 75% (95% CI 73–76; table 2); with area under the diagnostic ROC curve (AUC) of 0·77 (95% CI 0·68–0·86). These performance estimates did not meet the minimum criteria for a tuberculosis triage test (table 2). 50 (83·6%) of 61 participants with prevalent tuberculosis had no symptoms compatible with tuberculosis disease, and the remaining 11 participants with at least one symptom consistent with tuberculosis had RISK11 scores of more than 80% (median 96%; figure 3; appendix p 14). Discrimination between symptomatic prevalent tuberculosis and symptomatic controls was high (AUC 0·97, 95% CI 0·95–0·99; figure 3) and, with a highly specific threshold, performance exceeded the optimal TPP for a tuberculosis triage test in this population. By contrast, RISK11 discriminated between asymptomatic controls and asymptomatic prevalent tuberculosis cases with an AUC of 0·75 (95% CI 0·66–0·84; figure 3).
In the secondary analysis of biomarker performance for incident tuberculosis, annualised incidence was 2·1 versus 0·8 per 100 person-years among the RISK11-positive versus RISK11-negative participants, respectively, which was equivalent to a 0·026 (95% CI 0·01–0·04) versus 0·010 (0·004–0·02) cumulative incident probability of developing tuberculosis disease over 15 months, respectively (figure 3). No incident tuberculosis cases were detected in RISK11-negative participants until 8·7 months (figure 3). Tuberculosis incidence through 15 months among RISK11-positive participants was 2·61 (95% CI 1·15–5·94) times higher than RISK11-negative participants (table 2); and the RISK11 signature discriminated between incident tuberculosis cases and controls with AUC of 0·63 (95% CI 0·47–0·80; figure 4). Over this period, at the predefined 60% threshold, RISK11 showed very low sensitivity of 25% (95% CI 12–46) with specificity of 91% (95% CI 91–91). At an exploratory RISK11 threshold of 26%, which provided 75% specificity, sensitivity was 47% (95% CI 26–74). By comparison, the prognostic sensitivity of IFNγ release assays over 15 months was 83% (62–100), but more than 60% of the population was IFNγ release assay positive (specificity 37%, 95% CI 35–40; table 2).Figure 4 Prognostic performance of RISK11 and treatment efficacy of 3HP
(A) ROC curve depicting RISK11 prognostic performance for incident tuberculosis through 15 months of follow-up. The shaded area represents 95% CI. The grey and black dots depict the minimum and optimal criteria, respectively, set out in the WHO target product profile for an incipient tuberculosis test. (B) RISK11 performance (area under the ROC curve) for endpoints within a 6-month sliding window from month 0 through 15. The shaded area represents 95% CI. (C) ROC curves depicting RISK11 prognostic performance for incident tuberculosis through expanding follow-up periods. The grey and black dots depict the minimum and optimal criteria, respectively, set out in the WHO target product profile for an incipient tuberculosis test. (D) Cumulative incidence of tuberculosis in RISK11-positive participants who were randomly assigned to 3HP (six cases, red line) and RISK11-positive participants who were randomly assigned to observation (14 cases, blue line) during follow-up. The shaded areas represent 95% CI. (E) Cumulative incidence of tuberculosis in participants who met criteria for treatment adherence per protocol, stratified into RISK11-positive participants who were randomly assigned to 3HP (four cases, red line) and RISK11-positive participants who were randomly assigned to observation (14 cases, blue line) during follow-up. (F) TE estimated through follow-up in participants who met criteria for treatment adherence per protocol. The shaded areas represent 95% CI. TRP=true positive rate. FPR=false positive rate. AUC=area under the receiver operating characteristic curve. TPP=target product profile. TE=treatment efficacy.
RISK11 prognostic performance was highly dependent on time to disease. Instantaneous RISK11 performance, estimated from 6-month sliding windows, showed prognostic discrimination was high (AUC >0·80) for approximately 9 months, before waning towards 0·58 between months 9 and 15 (figure 4; appendix p 16). Prognostic performance of RISK11 for incident tuberculosis within 6 months (AUC 0·95, 95% CI 0·92–1·0) exceeded the optimal TPP for an incipient tuberculosis test (appendix p 16), and for tuberculosis disease within 12 months (0·80, 0·65–0·94; figure 4) approached the minimum TPP (appendix p 16), but over a 15-month period did not meet minimum criteria for a prognostic tuberculosis test (table 2).
In the primary analysis of treatment efficacy among RISK11-positive participants, tuberculosis incidence in the 3HP-positive and 3HP-negative groups was 1·94 cases per 100 person years and 2·09 cases per 100 person years, respectively (figure 4; table 1), with estimated treatment efficacy of 7·0% (95% CI −145 to 64·7) over 15 months. In the subgroup of 286 adherent participants who completed at least 11 doses within 16 weeks, efficacy was 22% (−138 to 74; figure 4) over 15 months. Notably, among adherent participants, there were no tuberculosis cases through 9 months (figure 4).
Adverse events related to 3HP were mostly of mild to moderate severity (appendix p 12). 67 serious adverse events, including 29 due to trauma, occurred in 65 participants. Serious adverse events occurred in 20 (5·3%) of 375 RISK11-positive participants who received 3HP (eight serious adverse events due to trauma), compared with 12 (1·6%) of 764 in RISK11-positive and 3HP-negative participants (Fisher's exact p<0·001). Among RISK11-negative participants, 33 (1·9%) of 1784 experienced serious adverse events. All but two serious adverse events were deemed unrelated to 3HP. Serious adverse events related to 3HP included one hospitalisation for seizures (unintentional isoniazid overdose) and one death of unknown cause (possibly temporally related). One death of unknown cause also occurred in an untreated RISK11-negative participant. There were 16 deaths in total, including five RISK11-positive participants receiving 3HP (three deaths due to trauma), three untreated RISK11-positive participants, and eight RISK11-negative participants.
3HP was halted in 28 (7·5%) of 375 participants, due to an adverse event of special interest (influenza-like illness or other possible hypersensitivity reaction) in 17 (4·5%), hepatotoxicity in one (0·3%), gastrointestinal symptoms in three (0·8%), and seizures in three (0·8%) participants.
RISK11 diagnostic and prognostic performance and treatment efficacy of 3HP based on the secondary endpoint definition (at least one sputum sample; appendix p 14) are described in the appendix (p 15).
Five (8·2%) of the 61 participants witih prevalent tuberculosis were resistant to isoniazid or rifampicin, or both. Two (6·7%) of the 30 participants with incident tuberculosis, both in the untreated group, were resistant to isoniazid and rifampicin. No participants were observed to have drug-resistant incident tuberculosis in the 3HP-positive group.
Discussion
Our goal was to evaluate a biomarker-targeted, community-based strategy to detect missing tuberculosis cases among people who do not seek health care, whose disease might not be detected by symptom-focused screening algorithms, and to prevent disease among those at highest risk of progression to tuberculosis. The RISK11 assay was an effective screening test for active disease in symptomatic participants, in whom performance exceeded the requirements for a triage test, but less so in asymptomatic participants. The RISK11 signature was able to predict risk for tuberculosis disease progression, in a trial population with tuberculosis incidence exceeding one case per 100 person-years, but optimal prognostic performance was limited to a 6-month horizon. While risk-targeted 3HP did not prevent tuberculosis disease over 15 months, there was some evidence of transient efficacy through 9 months among fully adherent participants.
Community-based recruitment of ambulant volunteers was not focused on individuals with known risk factors for tuberculosis, such as household contact. Individuals with recent previous history of tuberculosis (>3 years before screening) and HIV infection were excluded. Nevertheless, more than 1% of study volunteers had previously undiagnosed, microbiologically confirmed tuberculosis at enrolment, based on spontaneous expectorated rather than induced sputum samples. More than 80% of these baseline tuberculosis cases did not have any symptom compatible with tuberculosis disease and would not have been detected by a tuberculosis screening strategy that requires symptoms as the entry point to investigation. This finding is consistent with 46–79% prevalence (median 50%) of subclinical tuberculosis reported in prevalence surveys.12, 13, 14 It is not known whether subclinical tuberculosis would have progressed to symptomatic disease, spontaneously halted, or even reversed if left untreated,15, 16 nor whether subclinical disease directly contributes to M tuberculosis transmission.17 Further research is needed to determine the importance of detection, treatment, and prevention of subclinical disease for global tuberculosis control.
Although very few prevalent tuberculosis cases were symptomatic, RISK11 performance for discrimination of symptomatic prevalent tuberculosis cases from symptomatic controls exceeded the optimal TPP criteria for a triage test, while not meeting the stringent criteria for a confirmatory diagnostic test.5 A 2020 prospective observational study among symptomatic individuals who self-presented to a tuberculosis clinic assessed diagnostic accuracy of 27 transcriptomic signatures for discrimination between prevalent tuberculosis cases and controls.18 The 16-gene Zak signature, from which RISK11 was derived, did not meet the minimum WHO criteria for a triage test, but four of the 27 signatures met these criteria, suggesting that another signature might perform as well as or better than RISK11. RISK11 discrimination of asymptomatic prevalent tuberculosis cases from asymptomatic controls was modest and did not meet the minimal criteria for a triage test. These findings suggest that host blood biomarker development must consider that subclinical tuberculosis might be characterised by more heterogenous or less pronounced peripheral blood inflammatory responses than symptomatic tuberculosis, or both, which affects RNA signature performance. This finding is consistent with lower inflammatory profiles, observed by blood transcriptomic and proteomic analyses, during the subclinical phases of tuberculosis progression compared with subsequent symptomatic, active disease.19, 20 The modest performance characteristics for asymptomatic prevalent tuberculosis would limit applicability of RISK11 for biomarker-targeted, mass community screening in the South African setting, where the majority of baseline tuberculosis cases were subclinical. A host blood biomarker with good sensitivity and specificity for symptomatic tuberculosis might be most useful in countries with low to medium tuberculosis burden, where individuals with compatible symptoms might not otherwise be investigated for tuberculosis. Future diagnostic studies in symptomatic patients seeking health care should also include patients with extrapulmonary and culture-negative tuberculosis, particularly in HIV-infected cohorts, and the full spectrum of differential diagnoses that commonly mimic tuberculosis.
Prognostic performance of RISK11 for risk of progression to incident tuberculosis was poor through 15 months and did not meet the minimum TPP criteria for an incipient tuberculosis test through this prognostic horizon.4 However, good prognostic performance was observed for incident tuberculosis within 12 months of testing and performance exceeded the optimal TPP criteria for tuberculosis occurring within 6 months of testing. The positive predictive value for incident disease (1·9 vs 0·9 for RISK11 compared with IFNγ release assay, respectively) was computed from the observed tuberculosis incidence rate, which was lower than that typically used in estimations (2%).3, 6 It is not possible to determine whether the late incident tuberculosis cases occurring among RISK11-negative participants were due to reactivation or new M tuberculosis infection. We infer that a prognostic test with optimal short-term performance might be useful in identifying people who would benefit from an efficacious intervention in a low-incidence setting, in which the timing of M tuberculosis exposure is often known and subsequent exposure is unlikely.
The 3HP regimen was previously shown to be as effective as 9 months of isoniazid in preventing tuberculosis among individuals with known exposure or positive TST.21 Ethical equipoise of the intervention and control groups in this trial was based on the fact that RISK11 had been validated in selected case-control studies, which can overestimate biomarker performance, and thus risk for tuberculosis among RISK11-positive individuals needed to be tested prospectively in the field. Furthermore, although TPT is given commonly to IFNγ release assay-positive and tuberculin skin test-positive individuals, and individuals with known household exposure to a tuberculosis patient, the vast majority do not progress to tuberculosis disease if left untreated. The risk–benefit balance of 3HP preventive therapy for RISK11-positive individuals was unknown. However, we found no evidence that 3HP treatment reduced the rate of incident tuberculosis over 15 months in RISK11-positive individuals, who might be further advanced along the spectrum of tuberculosis pathogenesis.19 Interpretation of the results is limited by the wide CIs. It is also notable that no tuberculosis cases were observed in fully adherent participants through 9 months. This finding is consistent with the possibility that 3HP was sufficient to temporarily halt, but insufficient to sterilise, incipient tuberculosis, resulting in reactivation. A RISK11-targeted preventive therapy strategy for high tuberculosis transmission settings like South Africa might require a more potent therapeutic regimen than 3HP. 3HP might have been sufficient to sterilise incipient tuberculosis disease, but not to protect against tuberculosis disease resulting from reinfection after completion of the treatment course. Although it is not possible to distinguish between reactivation and reinfection tuberculosis cases in this study, we suggest that the limited time available for reinfection and subsequent progression to disease after completing 3HP makes the latter possibility less likely.
The study was subject to a number of limitations. The hybrid design required an open-label treatment group,2 with no placebo for RISK11-positive participants, so that risk for tuberculosis could also be evaluated in the control group while concealing RISK11 status from participants, site staff, and tuberculosis endpoint laboratory staff for analysis of biomarker performance. Tuberculosis case accrual during the latter stages of follow-up suggested no evidence of ascertainment bias during treatment. Extensive study simulations were done to inform the size of each group for the coprimary analyses. However, due to lower than expected prevalence of RISK11-positive status in the screened population (9·3% vs 15%), enrolment of 1139 RISK11-positive individuals required 2 years, compared with planned enrolment of 1500 RISK11-positive individuals over 1 year. As a result, fewer than expected incident tuberculosis outcomes were observed (24 vs 40 primary endpoints), which might have reduced power for both treatment efficacy and RISK11 performance analyses. Not all participants in the treatment group completed 3HP per protocol, because study drug was discontinued for suspected hypersensitivity reactions or influenza-like illnesses. However, the discontinuation rate (7·5%) was comparable to other trials of 3HP, in which study drug was discontinued in 17·9% of participants overall and in 4·9% due to an adverse event.21 The loss to follow-up rate in this trial (14·4%) was higher than expected and might reflect the challenges of retaining the study participants, in the absence of traditional tuberculosis risk factors for which surveillance is routine. However, loss to follow-up occurred predominantly after the treatment period and did not seem to have been biased by treatment factors. We note that median duration of participation was 13·9 months and thus loss to follow-up did not have major unforeseen effect on statistical power. Strengths of the study include enrolment in geographically distinct sites across South Africa that were representative of populations with different rates of IFNγ release assay positivity and tuberculosis disease, which were congruent with local rates of RISK11 positivity, although the sample size was not sufficient for analysis of signature performance or 3HP efficacy at site level. The findings broadly reflect the South African tuberculosis epidemic, but might not be directly applicable to countries with much lower tuberculosis incidence.
It is not yet known whether other parsimonious tuberculosis signatures, developed and validated like RISK11 in carefully curated case-control studies, will exhibit similar performance characteristics when prospectively tested in the field, where undiagnosed subclinical tuberculosis might pose a challenge to diagnostic performance. Head-to-head analyses of several transcriptomic tuberculosis signatures with promising diagnostic performance are currently underway on CORTIS samples and novel near-patient testing platforms are in development, which might bring cost-effective, community-based tuberculosis biomarker screening closer to implementation in the field. However, although we have shown that a strategy of biomarker-guided tuberculosis preventive therapy is feasible, the optimal preventive therapy regimen for use in such a strategy remains elusive.
Data sharing
Deidentified RISK11 signature scores and primary tuberculosis endpoint data from all participants will be available with publication. The dataset is deposited in Zivahub (https://doi.org/10.25375/uct.13573337.v1), an open access data repository hosted by the University of Cape Town's institutional data repository powered by Figshare for Institutions.
Supplementary Material
Supplementary appendix
Acknowledgments
The trial was funded by the Bill & Melinda Gates Foundation (OPP1116632, OPP1137034) and the Strategic Health Innovation Partnerships Unit of the South African Medical Research Council with funds received from the South African Department of Science and Technology. Rifapentine was donated by the manufacturer (Sanofi). The authors thank the members of the data and safety monitoring board and the trial steering committee.
Contributors
TJS, AF-G, AP-N, SS, GW, KN, GC, and MH designed the study. CI, WB, AH, STM, RH-M, MT, GW, KN, and GC recruited and evaluated participants. TJS, AP-N, SKM, SCM, KH, MM, NB, ME, LJ, and RR collected and analysed laboratory data. AF-G, and BB accessed and verified the data. TJS, AF-G, AP-N, HM, BB, TS, RGW, and MH analysed data and interpreted results. KH, CH, and MK provided operational support. TJS, AF-G, HM, and MH drafted the Article. All authors had full access to the data, and reviewed, revised and gave final approval of the Article before submission.
The CORTIS-01 Study Team
Kesenogile Baepanye, Tshepiso Baepanye, Ken Clarke, Marelize Collignon, Audrey Dlamini, Candice Eyre, Tebogo Feni, Moogo Fikizolo, Phinda Galane, Thelma Goliath, Alia Gangat, Shirley Malefo-Grootboom, Elba Janse van Rensburg, Bonita Janse van Rensburg, Sophy Kekana, Marietjie Zietsman, Adrianne Kock, Israel Kunene, Aneessa Lakhi, Nondumiso Langa, Hilda Ledwaba, Marillyn Luphoko, Immaculate Mabasa, Dorah Mabe, Nkosinathi Mabuza, Molly Majola, Mantai Makhetha, Mpho Makoanyane, Blossom Makhubalo, Vernon Malay, Juanita Market, Selvy Matshego, Nontsikelelo Mbipa, Tsiamo Mmotsa, Sylvester Modipa, Samuel Mopati, Palesa Moswegu, Primrose Mothaga, Dorothy Muller, Grace Nchwe, Maryna Nel, Lindiwe Nhlangulela, Bantubonke Ntamo, Lawerence Ntoahae, Tedrius Ntshauba, Nomsa Sanyaka, Letlhogonolo Seabela, Pearl Selepe, Melissa Senne, MG Serake, Maria Thlapi, Vincent Tshikovhi, Lebogang Tswaile, Amanda van Aswegen, Lungile Mbata, Constance Takavamanya, Pedro Pinho, John Mdlulu, Marthinette Taljaard, Naydene Slabbert, Sharfuddin Sayed, Tanya Nielson, Melissa Senne, Ni Ni Sein, Lungile Mbata (The Aurum Institute); Dhineshree Govender, Tilagavathy Chinappa, Mbali Ignatia Zulu, Nonhle Bridgette Maphanga, Senzo Ralph Hlathi, Goodness Khanyisile Gumede, Thandiwe Yvonne Shezi, Jabulisiwe Lethabo Maphanga, Zandile Patrica Jali, Thobelani Cwele, Nonhlanhla Zanele Elsie Gwamanda, Celaphiwe Dlamini, Zibuyile Phindile Penlee Sing, Ntombozuko Gloria Ntanjana, Sphelele Simo Nzimande, Siyabonga Mbatha, Bhavna Maharaj, Atika Moosa, Cara-Mia Corris (Centre for the AIDS Programme of Research in South Africa); Fazlin Kafaar, Marwou De Kock, Hennie Geldenhuys, Angelique Kany Kany Luabeya, Justin Shenje, Natasja Botes, Susan Rossouw, Hadn Africa, Bongani Diamond, Samentra Braaf, Sonia Stryers, Alida Carstens, Ruwiyda Jansen, Simbarashe Mabwe, Roxane Herling, Ashley Veldsman, Lebohgang Makhete, Marcia Steyn, Sivuyile Buhlungu, Margareth Erasmus, Ilse Davids, Patiswa Plaatjie, Alessandro Companie, Frances Ratangee, Helen Veldtsman, Christel Petersen, Charmaine Abrahams, Miriam Moses, Xoliswa Kelepu, Yolande Gregg, Liticia Swanepoel, Nomsitho Magawu, Nompumelelo Cetywayo, Lauren Mactavie, Habibullah Valley, Elizabeth Filander, Nambitha Nqakala, Angelique Mouton, Fajwa Opperman, Elma Van Rooyen, Petrus Tyambetyu (South African Tuberculosis Vaccine Initiative, University of Cape Town); Elizna Maasdorp, Justine Khoury, Belinda Kriel, Bronwyn Smith, Liesel Muller, Susanne Tonsing, Andre Loxton, Andriette Hiemstra, Petri Ahlers, Marika Flinn (DST/NRF Centre of Excellence for Biomedical TB Research and SAMRC Centre for TB Research, Stellenbosch University); and Eva Chung, Michelle Chung, Alicia Sato (Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Research Center)
Declaration of interests
TJS has a patent of the RISK11 signature pending and reports grants from the Bill and Melinda Gates Foundation and South African Medical Research Council. KN reports grants from CAPRISA. GW reports a patent (PCT/IB2019/052043) pending to University of Cape Town, Stellenbosch University, Max-Planck-Gesellschaft Zur Foerderung Der Wissenschaften EV, Seattle Children's Hospital Doing Business as Seattle Children's Research Institute, and UK Research and Innovation. GC reports grants from the Bill & Melinda Gates Foundation. AP-N has a patent of the RISK11 signature pending and reports grants from the Bill & Melinda Gates Foundation and the South African Medical Research Council. MH reports grants from the Bill & Melinda Gates Foundation and the South African Medical Research Council. | 15 MILLIGRAM/KILOGRAM, ONCE WEEKLY | DrugDosageText | CC BY | 33508224 | 20,168,180 | 2021-03 |
What was the dosage of drug 'PYRIDOXINE'? | Biomarker-guided tuberculosis preventive therapy (CORTIS): a randomised controlled trial.
Targeted preventive therapy for individuals at highest risk of incident tuberculosis might impact the epidemic by interrupting transmission. We tested performance of a transcriptomic signature of tuberculosis (RISK11) and efficacy of signature-guided preventive therapy in parallel, using a hybrid three-group study design.
Adult volunteers aged 18-59 years were recruited at five geographically distinct communities in South Africa. Whole blood was sampled for RISK11 by quantitative RT-PCR assay from eligible volunteers without HIV, recent previous tuberculosis (ie, <3 years before screening), or comorbidities at screening. RISK11-positive participants were block randomised (1:2; block size 15) to once-weekly, directly-observed, open-label isoniazid and rifapentine for 12 weeks (ie, RISK11 positive and 3HP positive), or no treatment (ie, RISK11 positive and 3HP negative). A subset of eligible RISK11-negative volunteers were randomly assigned to no treatment (ie, RISK11 negative and 3HP negative). Diagnostic discrimination of prevalent tuberculosis was tested in all participants at baseline. Thereafter, prognostic discrimination of incident tuberculosis was tested in the untreated RISK11-positive versus RISK11-negative groups, and treatment efficacy in the 3HP-treated versus untreated RISK11-positive groups, during active surveillance through 15 months. The primary endpoint was microbiologically confirmed pulmonary tuberculosis. The primary outcome measures were risk ratio [RR] for tuberculosis of RISK11-positive to RISK11-negative participants, and treatment efficacy. This trial is registered with ClinicalTrials.gov, NCT02735590.
20 207 volunteers were screened, and 2923 participants were enrolled, including RISK11-positive participants randomly assigned to 3HP (n=375) or no 3HP (n=764), and 1784 RISK11-negative participants. Cumulative probability of prevalent or incident tuberculosis disease was 0·066 (95% CI 0·049 to 0·084) in RISK11-positive (3HP negative) participants and 0·018 (0·011 to 0·025) in RISK11-negative participants (RR 3·69, 95% CI 2·25-6·05) over 15 months. Tuberculosis prevalence was 47 (4·1%) of 1139 versus 14 (0·78%) of 1984 in RISK11-positive compared with RISK11-negative participants, respectively (diagnostic RR 5·13, 95% CI 2·93 to 9·43). Tuberculosis incidence over 15 months was 2·09 (95% CI 0·97 to 3·19) vs 0·80 (0·30 to 1·30) per 100 person years in RISK11-positive (3HP-negative) participants compared with RISK11-negative participants (cumulative incidence ratio 2·6, 95% CI 1·2 to 5·9). Serious adverse events related to 3HP included one hospitalisation for seizures (unintentional isoniazid overdose) and one death of unknown cause (possibly temporally related). Tuberculosis incidence over 15 months was 1·94 (95% CI 0·35 to 3·50) versus 2·09 (95% CI 0·97 to 3·19) per 100 person-years in 3HP-treated RISK11-positive participants compared with untreated RISK11-positive participants (efficacy 7·0%, 95% CI -145 to 65).
The RISK11 signature discriminated between individuals with prevalent tuberculosis, or progression to incident tuberculosis, and individuals who remained healthy, but provision of 3HP to signature-positive individuals after exclusion of baseline disease did not reduce progression to tuberculosis over 15 months.
Bill and Melinda Gates Foundation, South African Medical Research Council.
Introduction
Large-scale prevention of progression from Mycobacterium tuberculosis infection to tuberculosis disease is key to achieving WHO End TB Strategy targets, yet tuberculin skin tests (TST) and interferon (IFN) γ release assays have poor specificity for incident tuberculosis.1 A biomarker-targeted prevention strategy using a highly specific correlate of risk (COR) for incident tuberculosis, in tandem with effective short-course tuberculosis preventive therapy (TPT),2 might impact the epidemic by preventing incident tuberculosis disease before transmission.3 Modelling suggests a three-times reduction in burden of TPT if targeted by COR, compared with IFNγ release assays and TST.4 Furthermore, because active tuberculosis disease should be excluded before starting TPT, additional utility of the prognostic COR as a screening (triage) test to identify undiagnosed tuberculosis disease would allow earlier curative treatment. WHO and FIND have developed target product profiles (TPP) for triage tests for tuberculosis (optimal and minimum sensitivity of >95% and >90%, and specificity of >80% and >70%, respectively),5 and incipient tuberculosis tests (minimum sensitivity and specificity of 75% and 75%, and optimal sensitivity and specificity of 90% and 90%, respectively).6
Research in context
Evidence before this study
Host blood RNA signatures have potential as tuberculosis triage or diagnostic tests, and as predictive tests to target tuberculosis preventive therapy. We searched MEDLINE, Scopus, Web of Science, and EBSCO libraries for publications between Jan 1, 2005, and May 31, 2020, using the search terms “Tuberculosis” OR “TB” OR “Mycobacterium tuberculosis” OR “MTB” AND “diagnosis” OR “diagnostic” OR “detect” OR “predic”OR “prognosis” OR “prognostic” OR “screen” AND “Blood Biomarker” OR “blood biomarkers” OR “bio-signature” OR “gene expression” OR “genetic transcription” OR “host blood” OR “immune marker” OR “immunologic marker” OR “Ribonucleic Acid” OR “RNA” OR “signature” OR “surrogate endpoint” OR “surrogate marker” OR “transcriptome” OR “transcriptomic” AND “Area under curve” OR “AUC” OR “receiver operating characteristic” OR “ROC” OR “Accuracy” OR “Performance” OR “sensitivity” OR “specificity”. Studies comparing blood RNA signatures in individuals with tuberculosis versus Mycobacterium tuberculosis-uninfected controls, individuals with other respiratory diseases, or with M tuberculosis infection and using a microbiological reference standard of either sputum M tuberculosis culture, Xpert MTB/RIF, or smear microscopy for tuberculosis diagnosis, were included.
28 studies reported evaluation of 32 host blood RNA signatures for diagnosis or prediction of progression to tuberculosis disease in 83 cohorts. Only two studies prospectively tested performance of an RNA signature in all evaluable participants; the remainder used a case-control design. Multiple studies have tested tuberculosis preventive therapy in people with M tuberculosis latent tuberculosis infection. No studies have tested efficacy of tuberculosis preventive therapy to avert disease in RNA signature-positive people.
Added value of this study
This large randomised, controlled trial in five South African communities prospectively tested diagnostic and prognostic performance of an RNA signature (RISK11) in all evaluable participants, and estimated efficacy of tuberculosis preventive therapy to avert disease in RNA signature-positive people. More than 1% of HIV-uninfected community volunteers had previously undiagnosed, microbiologically confirmed tuberculosis at screening, more than 80% of which was asymptomatic. RISK11 showed moderate performance for tuberculosis triage, but good performance for diagnosis of symptomatic tuberculosis, and for short-term prediction of incident tuberculosis. 3 months of once-weekly, high-dose isoniazid and rifapentine (3HP) did not reduce incident disease in RISK11-positive individuals over 15 months of follow-up.
Implications of all the available evidence
Host blood biomarker development must consider that subclinical tuberculosis might be characterised by more heterogenous, or less pronounced blood inflammatory responses than symptomatic tuberculosis, or both, which will affect RNA signature performance. RISK11 might be better suited to screening of symptomatic individuals with possible tuberculosis than for mass community-based screening. RISK11 can identify those at highest risk for short-term progression to disease, but a more potent regimen than 3HP might be needed to prevent tuberculosis in RISK11-positive individuals.
We previously developed a 16-gene transcriptomic signature by whole blood RNA sequencing for identification of individuals at high risk of developing tuberculosis (the Zak16 signature).7, 8 Measurement of Zak16 was adapted to quantitative RT-PCR (RT-qPCR), and predictive ability for incident tuberculosis was validated in an independent longitudinal cohort of household contacts of tuberculosis patients.8 We reduced this signature to 11 genes (RISK11) with equivalent performance,9, 10 to allow testing in 96-well PCR format. Zak16 and RISK11 also did well as non-sputum screening tests for prevalent, active tuberculosis in case-control studies, measured by RNA sequencing, microarray,7, 8 or microfluidic RT-qPCR.9, 10 In a 2020 systematic review and patient-level pooled meta-analysis of 17 transcriptomic signatures for prognosis of incident tuberculosis, Zak16 was among eight signatures that achieved a positive predictive value above the WHO TPP benchmark for incipient tuberculosis tests.11 Since case-control studies might overestimate performance characteristics, testing in unselected populations is needed.
We report on a randomised controlled trial (CORTIS; NCT02735590), which prospectively measured diagnostic and prognostic performance of RISK11 for triage of prevalent and prediction of incident tuberculosis in South African adults; and, in parallel, estimated efficacy of short-course TPT to avert incident disease in RISK11-positive individuals.
Methods
Study design
This randomised controlled trial used a hybrid treatment selection, three-group study design to evaluate efficacy of the intervention and, in parallel, performance of the biomarker used to allocate that intervention (figure 1).2 The coprimary aims were to test, over 15 months, whether RISK11 status differentiates between people with and without cumulative prevalent or incident tuberculosis; and whether preventive therapy (weekly high-dose isoniazid and rifapentine for 12 weeks [3HP]) reduces tuberculosis incidence among RISK11-positive people compared with active surveillance only. RISK11 performance to detect prevalent tuberculosis was evaluated in all groups at baseline. RISK11 performance to predict incident tuberculosis was evaluated in the untreated RISK11-positive and RISK11-negative groups, and treatment efficacy was estimated from the 3HP treated and untreated RISK11-positive groups, after omitting participants with baseline tuberculosis. Efficiency of the hybrid study design was maximised by using the RISK11-positive and 3HP-negative group to evaluate both biomarker performance and treatment efficacy.Figure 1 Study design
The prevalence of RISK11 positivity was not precisely known in the study population; therefore, the number of individuals to be screened and the randomisation of RISK11-negative participants to enrolment was monitored and adjusted adaptively to ensure concurrent enrolment of the target number of RISK11-positive and RISK11-negative participants, per protocol specifications. The study used a three-group design to evaluate efficacy of the intervention and, in parallel, performance of the biomarker used to allocate that intervention. Diagnostic performance for differentiation of prevalent tuberculosis was tested in all three groups at baseline; prognostic performance for differentiation of incident tuberculosis over 15 months was tested in the two untreated groups (untreated RISK11 positive and untreated RISK11 negative); and treatment efficacy of 3HP over 15 months was tested in the two RISK11-positive groups (treated and untreated RISK11 positive). *Participants evaluated for eligibility at screening and enrolment. †Groups randomly assigned in blocks to ensure concurrent enrolment.
Routine implementation of TPT requires that patients are screened to exclude prevalent tuberculosis before TPT is provided to prevent incident disease. Therefore, because risk for prevalent and incident tuberculosis by RISK11 status must be understood before efficacy of preventive therapy against incident tuberculosis in RISK11-positive people can be interpreted, these secondary analyses are presented before the primary analysis of treatment efficacy.
The trial protocol (appendix p 21) was approved by the South African Health Products Regulatory Agency (20160305) by the Institutional Human Ethics Committees of participating sites; and was registered on ClinicalTrials.gov (NCT02735590). All participants provided written informed consent in their language of choice.
Participants
Adult volunteers living in tuberculosis-endemic communities in South Africa were recruited at five sites (South African Tuberculosis Vaccine Initiative, Worcester; Immunology Research Group, Stellenbosch University, Ravensmead; Aurum Institute, Klerksdorp and Rustenberg; and Centre for the AIDS Programme of Research in South Africa, Durban). Community-based recruitment was by word-of-mouth, house-to-house visits, and liaison with non-governmental organisations. Recruitment did not target groups at high risk of tuberculosis, such as household contacts. Eligible participants were aged between 18 years and 59 years, HIV-negative, without a history of tuberculosis disease in the last 3 years or preselected comorbidities (appendix p 8).
Screening
Venous blood was collected in PAXgene RNA tubes from all potentially eligible people at screening, frozen at −20°C, and shipped weekly to the South African Tuberculosis Vaccine Initiative Immunology Laboratory for RISK11 testing by qRT-PCR assay. Participants with a RISK11 score of at least 60% were classified a priori as RISK11 positive and less than 60% as RISK11 negative. This 60% threshold was the optimal point at which sensitivity and specificity for prognosis of incident tuberculosis were balanced in case-control studies.2 Samples with failed reference primer-probe reactions, with marked deviation in internal positive control sample from historical runs, or more than 30% failed interferon-stimulated genes primer-probe reactions (see quality control criteria and analysis script in Bitbucket instance) were classified as indeterminate. Per-participant qualitative results (RISK11 positive and RISK11 negative) were provided to the Triclinium Clinical Development (TCD) Data Centre for participant randomisation (see appendix pp 2–3).
Randomisation and masking
Assignment to study group was managed by an unmasked randomisation team from the TCD Data Centre, based on RISK11 status. RISK11-positive volunteers were randomly assigned (1:2; block size 15) to either open-label 3HP (3HP-positive group), or active tuberculosis surveillance without 3HP (3HP-negative group), in accordance with a randomisation schedule generated using SAS, version 9.4. RISK11-negative volunteers were concurrently randomly assigned either to active tuberculosis surveillance (3HP-negative group) or to non-participation, to enrich the study population for RISK11-positive participants.
Study group allocation was revealed to site staff after enrolment of eligible participants within 28 days of screening. The 3HP-negative group was double-blinded to RISK11 status, but unblinded to treatment allocation; the 3HP-positive group was unblinded to both RISK11-positive status and treatment allocation (figure 1). RISK11-positive participants randomly assigned to active surveillance did not receive a placebo, to maintain blinding of participants and study team members to RISK11 status.
Procedures
Target enrolment was maximally 3200 participants (1500 RISK11 positive and 1700 RISK11 negative). The randomisation ratio for RISK11-negative volunteers was adapted to ensure concurrent enrolment of the recruitment target. Adaptations occurred at intervals, informed by 3-monthly operational monitoring reports based on enrolment rate, RISK11-positive and RISK11-negative prevalence, and tuberculosis case accrual blinded to RISK11 status (appendix p 7).
Enrolment procedures included phlebotomy for IFNγ release assays (QuantiFERON TB Gold-Plus, Qiagen), tuberculosis symptom screen (a positive tuberculosis symptom screen included one or more symptoms of persistent unexplained cough, fever, night sweats, weight loss, or any haemoptysis), and collection of two spontaneous expectorated sputum samples for Xpert MTB/RIF assay (Cepheid) from all sputum-productive participants, regardless of symptoms.
All participants attended up to seven study visits, including four study site visits at months 3, 6, 12, and 15 (end of study), and three telephonic contact or field visits at months 1, 2, and 9. HIV testing was repeated at months 6 and 12.
Participants in the 3HP group received open-label, high-dose isoniazid (15 mg/kg; maximum dose 900 mg) with pyridoxine supplementation (25 mg) and rifapentine based on body weight (>32–50 kg, 750 mg; >50 kg, 900 mg), given weekly as directly observed oral doses, ideally with food, over 12 weeks. Completion of 3HP treatment was defined as receipt of 11 doses within 16 weeks (appendix p 3).
Outcomes
The two primary outcome measures were RISK11-positive to RISK11-negative risk ratio (RR) for prevalent or incident tuberculosis disease, and 3HP treatment efficacy through 15 months. Diagnostic performance for prevalent tuberculosis was evaluated on the presence of tuberculosis at the enrolment visit within the ITT cohort.
Participants in the 3HP group had each dose directly observed by study staff, and attended clinic for evaluation of solicited adverse events and possible adverse events of special interest at weeks 1–11. Solicited adverse events included gastrointestinal signs and symptoms suggestive of hepatotoxicity, such as nausea, vomiting, and jaundice. Possible hypersensitivity reactions, including influenza-like illness, were reported as adverse events of special interest. Safety events meeting the definition for a serious adverse event, whether deemed related or unrelated to study drug, were reported for both all participants through end of study.
Statistical analysis
The intention-to-treat (ITT) cohort included all enrolled participants who completed investigation for tuberculosis endpoints at baseline. The modified intention-to-treat (mITT) cohort included all participants in the ITT population who completed at least one post-baseline tuberculosis endpoint investigation and omitted participants with endpoint-defined tuberculosis disease at baseline (prevalent tuberculosis).
The diagnostic RR was estimated as a proportion of participants with tuberculosis disease among RISK11-positive divided by RISK11-negative participants. Prognostic performance for incident tuberculosis after enrolment was evaluated among 3HP-negative participants within the mITT cohort (ie, excluding participants with tuberculosis at baseline). Prognostic RR was estimated as the cumulative incidence through 15 months for RISK11-positive divided by RISK11-negative participants. The primary RR was an estimate of the probability of having prevalent tuberculosis or developing incident tuberculosis among RISK11-positive divided by RISK11-negative participants; this combined probability of prevalent and incident tuberculosis was computed for each group as the probability of prevalent tuberculosis plus the probability of incident tuberculosis through 15 months (conditioned on not having prevalent tuberculosis). Efficacy of 3HP preventive therapy to reduce the rate of incident tuberculosis disease compared with the untreated RISK11-positive participants was also evaluated in the mITT population. Treatment efficacy was estimated as one minus the cumulative incidence of RISK11-positive and 3HP-positive participants divided by RISK11-positive and 3HP-negative participants through 15 months. A per-protocol analysis of treatment efficacy was done and excluded RISK11-positive and 3HP-positive participants that received less than 11 of the 12 weekly doses of 3HP.
For statistical efficiency, a random subset of RISK11-negative participants were enrolled, therefore creating an ITT cohort artificially enriched with RISK11-positive participants. Therefore, unless stated otherwise, all analyses were adjusted so that results reflected the screened population. Secondary performance metrics such as sensitivity and specificity were estimated using standard formulas with binary endpoints; a percentile bootstrap with 20 000 samples was used to estimate 95% CIs. For descriptive analyses (Table 1, Table 2), rank-based Wilcoxon rank-sum tests were used to compare continuous variables in RISK11-positive versus RISK11-negative groups. Fisher's exact test was used to compare binary readouts; p values in Table 1, Table 2 were not adjusted for multiple comparisons. The prespecified statistical analysis plan is included in the appendix (p 82) and contains detailed description of the statistical methods.Table 1 Baseline characteristics and primary tuberculosis endpoints by group
Total (n=2923) RISK11 positive and 3HP positive (n=375) RISK11 positive and 3HP negative (n=764) RISK11 negative (n=1784) RISK11 positive vs RISK11 negative, p value*
Sex
Female 1585 (54·2%) 213 (56·8%) 469 (61·4%) 903 (50·6%) <0·001
Male 1338 (45·8%) 162 (43·2%) 295 (38·6%) 881 (49·4%) ..
Age, years 28·5 (9·0) 28·8 (9·5) 28·4 (9·2) 28·4 (8·7) 0·541
Race or ethnicity
Asian 4 (0·1%) 0 1 (0·1%) 3 (0·2%) 0·567
Black African 1947 (66·6%) 227 (60·5%) 477 (62·4%) 1243 (69·7%) <0·001
White 4 (0·1%) 0 1 (0·1%) 3 (0·2%) 0·567
Mixed race 968 (33·1%) 148 (39·5%) 285 (37·3%) 535 (30·0%) <0·001
Body-mass index, kg/m2 24·6 (7·7) 24·1 (6·3) 24·4 (6·1) 24·9 (8·6) 0·354
Previous tuberculosis 230 (7·9%) 36 (9·6%) 75 (9·8%) 119 (6·7%) 0·003
Smoking 1478 (50·6%) 203 (54·1%) 391 (51·2%) 884 (49·6%) 0·170
Family tuberculosis history 462 (15·8%) 66 (17·6%) 110 (14·4%) 286 (16·0%) 0·675
Interferon γ release assay positive 1895 (64·8%) 250 (66·7%) 528 (69·1%) 1117 (62·6%) <0·001
Follow-up, months 15 (9·4–15·0) 15 (11·1–15·0) 15 (9·1–15·0) 13·6 (9·4–15·0) 0·056
Prevalent tuberculosis, n (probability, 95% CI) 61 (1·1%, 0·77–1·6)† 47 (4·1%, 3·1–5·4)‡ 47 (4·1%, 3·1–5·4)§ 14 (0·78%, 0·47–1·3) NA
Incident tuberculosis, n (cases per 100 person years, 95% CI) 24 (1·05, 0·59–1·5)§ 6 (1·9, 0·35–3·5) 14 (2·09, 0·97–3·19) 10 (0·80, 0·30–1·30) NA
Cumulative tuberculosis, n (probability, 95% CI)¶ 85 (0·022, 0·016–0·028)† 61 (0·066, 0·049–0·084)‖** 61 (0·066, 0·049–0·084)** 24 (0·018, 0·011–0·026) NA
Data are n (%), mean (SD), or median (IQR), unless stated otherwise. Secondary tuberculosis endpoints by group are in the appendix (p 13). NA=not applicable.
* For continuous data, p values from Wilcoxon rank sum test. For categorical data, p values from Fischer's exact test.
† Overall rate estimates are weighted combinations of the enrolled participants to reflect the screened population.
‡ Overall incidence and cumulative tuberculosis excludes RISK11-positive and 3HP-positive incident cases.
§ Prevalent tuberculosis among RISK11 positive was assessed by combining the 3HP-negative and 3HP-positive groups. Value is repeated for RISK11 positive and 3HP positive, and RISK11 positive and 3HP negative.
¶ Probability of observing prevalent or incident tuberculosis over 15 months.
‖ Probability of prevalent or incident tuberculosis not estimated for RISK11-positive and 3HP-positive because it would combine data from before and after 3HP treatment and is therefore potentially misleading.
** Estimate for RISK11 positive includes 3HP-positive prevalent cases and 3HP-negative prevalent and incident cases. Value is repeated for RISK11 positive and 3HP positive, and RISK11 positive and 3HP negative.
Table 2 Performance of RISK11 and IGRA for prevalent and incident tuberculosis
Prevalent tuberculosis (ITT cohort) Incident tuberculosis (mITT cohort)*
RISK11 (60)† RISK11 (26)† IGRA RISK11 (60)† RISK11 (26)† IGRA
Risk ratio 5·13 (2·93 to 9·43) 7·39 (3·46 to 25·69) 4·43 (1·93 to 14·18) 2·61 (1·15 to 5·94) 2·67 (1·04 to 8·66) 2·83 (0·95 to 99·79)
Biomarker prevalence 9·2% (9·2 to 9·2) 25·8% (24·1 to 27·4) 63·4% (61·3 to 65·4) 9·0% (9·0 to 9·0) 25·3% (23·7 to 26·9) 63·2% (61·1 to 65·3)
AUC‡ 0·77 (0·68 to 0·86) .. 0·66 (0·58 to 0·73) 0·63 (0·47 to 0·80) .. 0·67 (0·54 to 0·79)
Sensitivity 34·9% (23·7 to 52·2) 72·1% (54·5 to 90·2) 88·7% (77·1 to 96·4) 25·0% (12·7 to 45·9) 47·5% (25·9 to 75·0) 83·2% (61·9 to 100·0)
Specificity 91·0% (90·9 to 91·1) 74·7% (73·1 to 76·4) 36·9% (34·9 to 39·0) 91·1% (91·0 to 91·2) 74·9% (73·2 to 76·5) 37·0% (34·9 to 39·1)
PPV§ 4·1% (3·0 to 5·4) 3·1% (2·0 to 4·3) 1·5% (1·0 to 2·2) 1·9% (0·9 to 3·0) 1·3% (0·6 to 2·1) 0·9% (0·5 to 1·4)
PPV (2% incidence)¶ .. .. .. 6·7% (3·5 to 11·8) 4·6% (2·5 to 7·1) 3·3% (2·5 to 3·9)
NPV§ 99·2% (98·8 to 99·6) 99·6% (99·2 to 99·9) 99·7% (99·3 to 99·9) 99·4% (99·0 to 99·8) 99·5% (99·1 to 99·9) 99·7% (99·2 to 100·0)
NPV (2% incidence)¶ .. .. .. 97·9% (97·6 to 98·5) 98·2% (97·5 to 99·2) 98·8% (97·4 to 100·0)
NNS or NNT‖ 29·9 (21·8 to 46·6) 37·8 (25·5 to 65·7) 83·1 (53·2 to 179·8) 75·1 (40·4 to 277·5) 123·8 (47·2 to 834·1) 168 (−440 to 1059)
Data are risk ratio (95 %CI), % (95% CI), AUC (95% CI), or NNS or NNT (95% CI). ITT=intention to treat. mITT=modified intention-to-treat. IGRA=interferon γ release assay. AUC=area under the receiver operating characteristic curve. PPV=positive predictive value. NPV=negative predictive value. NNS=number needed to screen. NNT=number needed to treat.
* Computed over 15-month prognostic window. Performance of RISK11 and IGRA for incident tuberculosis over 6-month and 12-month prognostic windows is in the appendix (p 16).
† RISK11 score threshold at 60% or 26%.
‡ AUC is computed across all score thresholds and value is presented under RISK11 (60).
§ Computed using the prevalence and incidence rates in the trial population as appropriate.
¶ Computed assuming 2% annual incidence of tuberculosis in the population.
‖ NNS for prevalent tuberculosis; NNT for incident tuberculosis. Performance of RISK11 and IGRA for prevalent and incident tuberculosis based on secondary endpoint (≥1 sample+) is in the appendix (p 15).
The study was designed to have 90% power to reject the null hypothesis of a RISK11-positive and RISK11-negative cumulative risk ratio less than 2 with one-sided alpha of 0·025. For treatment efficacy there was 80% power to reject the null hypothesis of efficacy less than 20%, with one-sided alpha of 0·05 and under the alternative design hypothesis that efficacy was 80%. To compute statistical power for these aims, a stochastic simulation of the trial was constructed, based on which we expected to observe 33 tuberculosis disease endpoints among 1500 RISK11-positive participants and seven tuberculosis disease endpoints among 1700 RISK11-negative participants (appendix p 6).
Role of the funding source
The trial was funded by the Bill & Melinda Gates Foundation (OPP1116632, OPP1137034) and the Strategic Health Innovation Partnerships Unit of the South African Medical Research Council, with funds received from the South African Department of Science and Technology. The Gates Foundation contributed to the study design. The regulatory sponsor was the University of Cape Town. Rifapentine (PRIFTIN) was donated by the manufacturer (Sanofi), who had no role in the design, implementation, analysis, or reporting of the trial. All authors had access to all the data reported in the study. The corresponding author had final responsibility for the decision to submit for publication.
Results
Between Sept 20, 2016, and Oct 19, 2018, 20 207 volunteers consented to participation; 16 248 met inclusion criteria at screening and 15 777 with a RISK11 result were potentially eligible for enrolment (figure 2). Of the 20 207 adults assessed for eligibility, common reasons for exclusion included HIV infection (1246 [6·1%]) and comorbid conditions (1369 [6·8%]; appendix p 8). 2923 eligible participants were enrolled after randomisation (1784 [61·0%] RISK11 negative and 1139 [39·0%] RISK11 positive; table 1).Figure 2 Trial profile
ITT=intention to treat. mITT=modified intention to treat. LTFU=lost to follow-up. PP=per protocol analysis. *585 participants did not complete the trial for reasons including: 53 (9%) pregnancies, 22 (4%) investigator withdrawals, 46 (8%) consent withdrawals, 26 (4%) HIV infections, 422 (72%) LTFU, and 16 (3%) deaths.
Participants were enrolled at five geographically diverse sites across South Africa (appendix pp 9–11). Among participants with a RISK11 result, 1434 (9·3%) of 15 494 were RISK11 positive, with the proportion ranging from 6·2% to 13·0% across the five sites. RISK11-positive participants were randomly asigned either to receive treatment (375 [32·9%] RISK11 positive and 3HP positive) or undergo observation without treatment (764 [67·1%] RISK11 positive and 3HP negative).
There were no significant differences in smoking history, family history of tuberculosis, or febrile illness between RISK11-positive and RISK11-negative participants (table 1). A higher proportion of RISK11-positive (75 [9·8%] of 364) than RISK11-negative (119 [6·7%] of 1784) participants reported previous tuberculosis disease (p=0·003). Compared with RISK11 negative participants, a greater proportion of RISK11-positive participants were female and mixed race (p<0·001; table 1).
Median duration of follow-up for incident tuberculosis was 13·9 months (IQR 9·0–15·0) and 1879 (66%) of 2500 3HP-negative mITT participants attended at least six scheduled visits. 1416 (49%) of 2838 participants were followed up for 15 months and 2160 (75%) of 2838 participants were followed up for at least 9 months. 585 (21%) of 2838 participants did not complete the study because of withdrawal, death, or loss to follow-up (figure 2; table 1).
Among 91 participants with tuberculosis who reached the primary endpoint, 61 were diagnosed with prevalent tuberculosis at baseline (47 RISK11 positive and 14 RISK11 negative; table 1; appendix p 13). Prevalence of tuberculosis in RISK11-positive and RISK11-negative participants was 4·1% (95% CI 3·1–5·4) and 0·78% (0·5–1·3), respectively (figure 3). Thereafter, 24 participants in the untreated group were diagnosed with incident tuberculosis disease (14 RISK11 positive and ten RISK11 negative; table 1; appendix p 13) with overall incidence of 1·05 cases (95% CI 0·59–1·5) per 100 person-years.Figure 3 RISK11 detection of combined prevalent and incident tuberculosis and diagnostic performance
(A) Prevalence of tuberculosis in RISK11-positive (47 cases,) and RISK11-negative (14 cases, red bar) participants at trial enrolment. Error bars depict 95% CI. Cumulative incidence probability of tuberculosis in RISK11-positive (14 cases, blue line) or RISK11-negative (10 cases, red line) mITT participants during follow-up. Shaded areas represent 95% CI. (B) Ratio of RISK11-positive versus RISK11 negative cumulative incidence probability of observing prevalent or incident tuberculosis disease, in the ITT population of the observation group. (C) RISK11 signature scores (each dot represents a participant) measured at screening in trial participants, stratified on tuberculosis diagnosis. Boxes depict IQR, midline represents the median, and whiskers indicate range among enrolled participants. (D) RISK11 signature scores measured at screening in prevalent tuberculosis cases with or without any tuberculosis symptoms, in incident tuberculosis cases or those who did not have a tuberculosis diagnosis. The enrolled population, not the screened population, is represented in (C) and (D), because a large fraction of RISK11-negative participants were not enrolled by design. (E) ROC curves depicting RISK11 diagnostic performance for prevalent tuberculosis in the ITT population, for prevalent tuberculosis among individuals with no symptoms of tuberculosis (asymptomatic) and among individuals with at least one symptom consistent with tuberculosis disease (symptomatic). Shaded areas represent the 95% CI. The grey and black dots indicate the minimum and optimal criteria, respectively, set out in the WHO target product profile for a triage test. The empty dot indicates the criteria set out in the WHO target product profile for a confirmatory diagnostic test. TRP=true positive rate. ITT=intention to treat. FPR=false positive rate. AUC=area under the receiver operating characteristic curve.
In the primary analysis of biomarker performance for cumulative tuberculosis, cumulative probability of observing prevalent or incident tuberculosis disease in the ITT population was 0·066 (95% CI 0·049–0·084) in RISK11-positive participants and 0·018 (0·011–0·025) in RISK11-negative participants, with a risk ratio of 3·69 (95% CI 2·25–6·05) over 15 months (figure 3).
A wide range of RISK11 scores was observed, irrespective of tuberculosis outcome (figure 3). Among enrolled participants, those who remained tuberculosis free (controls) had significantly lower RISK11 scores (24·2%, IQR 8·2–75·3) than those with prevalent or incident tuberculosis disease (76·7%, 36·6–94·4; Wilcoxon rank-sum test p<0·0001; figure 3).
In the secondary analysis of biomarker performance for prevalent tuberculosis, using the prespecified RISK11 test threshold (60%) there was 5·13-times (95% CI 3·01–10·69) increased risk of prevalent tuberculosis disease at baseline in RISK11-positive versus RISK11-negative participants, with sensitivity of 35% (95% CI 24–52) and specificity of 91% (95% CI 91–91; table 2). The receiver operating characteristic (ROC) analysis (figure 3) showed that a RISK11 threshold of 26% provided sensitivity of 72% (95% CI 54–90) and specificity of 75% (95% CI 73–76; table 2); with area under the diagnostic ROC curve (AUC) of 0·77 (95% CI 0·68–0·86). These performance estimates did not meet the minimum criteria for a tuberculosis triage test (table 2). 50 (83·6%) of 61 participants with prevalent tuberculosis had no symptoms compatible with tuberculosis disease, and the remaining 11 participants with at least one symptom consistent with tuberculosis had RISK11 scores of more than 80% (median 96%; figure 3; appendix p 14). Discrimination between symptomatic prevalent tuberculosis and symptomatic controls was high (AUC 0·97, 95% CI 0·95–0·99; figure 3) and, with a highly specific threshold, performance exceeded the optimal TPP for a tuberculosis triage test in this population. By contrast, RISK11 discriminated between asymptomatic controls and asymptomatic prevalent tuberculosis cases with an AUC of 0·75 (95% CI 0·66–0·84; figure 3).
In the secondary analysis of biomarker performance for incident tuberculosis, annualised incidence was 2·1 versus 0·8 per 100 person-years among the RISK11-positive versus RISK11-negative participants, respectively, which was equivalent to a 0·026 (95% CI 0·01–0·04) versus 0·010 (0·004–0·02) cumulative incident probability of developing tuberculosis disease over 15 months, respectively (figure 3). No incident tuberculosis cases were detected in RISK11-negative participants until 8·7 months (figure 3). Tuberculosis incidence through 15 months among RISK11-positive participants was 2·61 (95% CI 1·15–5·94) times higher than RISK11-negative participants (table 2); and the RISK11 signature discriminated between incident tuberculosis cases and controls with AUC of 0·63 (95% CI 0·47–0·80; figure 4). Over this period, at the predefined 60% threshold, RISK11 showed very low sensitivity of 25% (95% CI 12–46) with specificity of 91% (95% CI 91–91). At an exploratory RISK11 threshold of 26%, which provided 75% specificity, sensitivity was 47% (95% CI 26–74). By comparison, the prognostic sensitivity of IFNγ release assays over 15 months was 83% (62–100), but more than 60% of the population was IFNγ release assay positive (specificity 37%, 95% CI 35–40; table 2).Figure 4 Prognostic performance of RISK11 and treatment efficacy of 3HP
(A) ROC curve depicting RISK11 prognostic performance for incident tuberculosis through 15 months of follow-up. The shaded area represents 95% CI. The grey and black dots depict the minimum and optimal criteria, respectively, set out in the WHO target product profile for an incipient tuberculosis test. (B) RISK11 performance (area under the ROC curve) for endpoints within a 6-month sliding window from month 0 through 15. The shaded area represents 95% CI. (C) ROC curves depicting RISK11 prognostic performance for incident tuberculosis through expanding follow-up periods. The grey and black dots depict the minimum and optimal criteria, respectively, set out in the WHO target product profile for an incipient tuberculosis test. (D) Cumulative incidence of tuberculosis in RISK11-positive participants who were randomly assigned to 3HP (six cases, red line) and RISK11-positive participants who were randomly assigned to observation (14 cases, blue line) during follow-up. The shaded areas represent 95% CI. (E) Cumulative incidence of tuberculosis in participants who met criteria for treatment adherence per protocol, stratified into RISK11-positive participants who were randomly assigned to 3HP (four cases, red line) and RISK11-positive participants who were randomly assigned to observation (14 cases, blue line) during follow-up. (F) TE estimated through follow-up in participants who met criteria for treatment adherence per protocol. The shaded areas represent 95% CI. TRP=true positive rate. FPR=false positive rate. AUC=area under the receiver operating characteristic curve. TPP=target product profile. TE=treatment efficacy.
RISK11 prognostic performance was highly dependent on time to disease. Instantaneous RISK11 performance, estimated from 6-month sliding windows, showed prognostic discrimination was high (AUC >0·80) for approximately 9 months, before waning towards 0·58 between months 9 and 15 (figure 4; appendix p 16). Prognostic performance of RISK11 for incident tuberculosis within 6 months (AUC 0·95, 95% CI 0·92–1·0) exceeded the optimal TPP for an incipient tuberculosis test (appendix p 16), and for tuberculosis disease within 12 months (0·80, 0·65–0·94; figure 4) approached the minimum TPP (appendix p 16), but over a 15-month period did not meet minimum criteria for a prognostic tuberculosis test (table 2).
In the primary analysis of treatment efficacy among RISK11-positive participants, tuberculosis incidence in the 3HP-positive and 3HP-negative groups was 1·94 cases per 100 person years and 2·09 cases per 100 person years, respectively (figure 4; table 1), with estimated treatment efficacy of 7·0% (95% CI −145 to 64·7) over 15 months. In the subgroup of 286 adherent participants who completed at least 11 doses within 16 weeks, efficacy was 22% (−138 to 74; figure 4) over 15 months. Notably, among adherent participants, there were no tuberculosis cases through 9 months (figure 4).
Adverse events related to 3HP were mostly of mild to moderate severity (appendix p 12). 67 serious adverse events, including 29 due to trauma, occurred in 65 participants. Serious adverse events occurred in 20 (5·3%) of 375 RISK11-positive participants who received 3HP (eight serious adverse events due to trauma), compared with 12 (1·6%) of 764 in RISK11-positive and 3HP-negative participants (Fisher's exact p<0·001). Among RISK11-negative participants, 33 (1·9%) of 1784 experienced serious adverse events. All but two serious adverse events were deemed unrelated to 3HP. Serious adverse events related to 3HP included one hospitalisation for seizures (unintentional isoniazid overdose) and one death of unknown cause (possibly temporally related). One death of unknown cause also occurred in an untreated RISK11-negative participant. There were 16 deaths in total, including five RISK11-positive participants receiving 3HP (three deaths due to trauma), three untreated RISK11-positive participants, and eight RISK11-negative participants.
3HP was halted in 28 (7·5%) of 375 participants, due to an adverse event of special interest (influenza-like illness or other possible hypersensitivity reaction) in 17 (4·5%), hepatotoxicity in one (0·3%), gastrointestinal symptoms in three (0·8%), and seizures in three (0·8%) participants.
RISK11 diagnostic and prognostic performance and treatment efficacy of 3HP based on the secondary endpoint definition (at least one sputum sample; appendix p 14) are described in the appendix (p 15).
Five (8·2%) of the 61 participants witih prevalent tuberculosis were resistant to isoniazid or rifampicin, or both. Two (6·7%) of the 30 participants with incident tuberculosis, both in the untreated group, were resistant to isoniazid and rifampicin. No participants were observed to have drug-resistant incident tuberculosis in the 3HP-positive group.
Discussion
Our goal was to evaluate a biomarker-targeted, community-based strategy to detect missing tuberculosis cases among people who do not seek health care, whose disease might not be detected by symptom-focused screening algorithms, and to prevent disease among those at highest risk of progression to tuberculosis. The RISK11 assay was an effective screening test for active disease in symptomatic participants, in whom performance exceeded the requirements for a triage test, but less so in asymptomatic participants. The RISK11 signature was able to predict risk for tuberculosis disease progression, in a trial population with tuberculosis incidence exceeding one case per 100 person-years, but optimal prognostic performance was limited to a 6-month horizon. While risk-targeted 3HP did not prevent tuberculosis disease over 15 months, there was some evidence of transient efficacy through 9 months among fully adherent participants.
Community-based recruitment of ambulant volunteers was not focused on individuals with known risk factors for tuberculosis, such as household contact. Individuals with recent previous history of tuberculosis (>3 years before screening) and HIV infection were excluded. Nevertheless, more than 1% of study volunteers had previously undiagnosed, microbiologically confirmed tuberculosis at enrolment, based on spontaneous expectorated rather than induced sputum samples. More than 80% of these baseline tuberculosis cases did not have any symptom compatible with tuberculosis disease and would not have been detected by a tuberculosis screening strategy that requires symptoms as the entry point to investigation. This finding is consistent with 46–79% prevalence (median 50%) of subclinical tuberculosis reported in prevalence surveys.12, 13, 14 It is not known whether subclinical tuberculosis would have progressed to symptomatic disease, spontaneously halted, or even reversed if left untreated,15, 16 nor whether subclinical disease directly contributes to M tuberculosis transmission.17 Further research is needed to determine the importance of detection, treatment, and prevention of subclinical disease for global tuberculosis control.
Although very few prevalent tuberculosis cases were symptomatic, RISK11 performance for discrimination of symptomatic prevalent tuberculosis cases from symptomatic controls exceeded the optimal TPP criteria for a triage test, while not meeting the stringent criteria for a confirmatory diagnostic test.5 A 2020 prospective observational study among symptomatic individuals who self-presented to a tuberculosis clinic assessed diagnostic accuracy of 27 transcriptomic signatures for discrimination between prevalent tuberculosis cases and controls.18 The 16-gene Zak signature, from which RISK11 was derived, did not meet the minimum WHO criteria for a triage test, but four of the 27 signatures met these criteria, suggesting that another signature might perform as well as or better than RISK11. RISK11 discrimination of asymptomatic prevalent tuberculosis cases from asymptomatic controls was modest and did not meet the minimal criteria for a triage test. These findings suggest that host blood biomarker development must consider that subclinical tuberculosis might be characterised by more heterogenous or less pronounced peripheral blood inflammatory responses than symptomatic tuberculosis, or both, which affects RNA signature performance. This finding is consistent with lower inflammatory profiles, observed by blood transcriptomic and proteomic analyses, during the subclinical phases of tuberculosis progression compared with subsequent symptomatic, active disease.19, 20 The modest performance characteristics for asymptomatic prevalent tuberculosis would limit applicability of RISK11 for biomarker-targeted, mass community screening in the South African setting, where the majority of baseline tuberculosis cases were subclinical. A host blood biomarker with good sensitivity and specificity for symptomatic tuberculosis might be most useful in countries with low to medium tuberculosis burden, where individuals with compatible symptoms might not otherwise be investigated for tuberculosis. Future diagnostic studies in symptomatic patients seeking health care should also include patients with extrapulmonary and culture-negative tuberculosis, particularly in HIV-infected cohorts, and the full spectrum of differential diagnoses that commonly mimic tuberculosis.
Prognostic performance of RISK11 for risk of progression to incident tuberculosis was poor through 15 months and did not meet the minimum TPP criteria for an incipient tuberculosis test through this prognostic horizon.4 However, good prognostic performance was observed for incident tuberculosis within 12 months of testing and performance exceeded the optimal TPP criteria for tuberculosis occurring within 6 months of testing. The positive predictive value for incident disease (1·9 vs 0·9 for RISK11 compared with IFNγ release assay, respectively) was computed from the observed tuberculosis incidence rate, which was lower than that typically used in estimations (2%).3, 6 It is not possible to determine whether the late incident tuberculosis cases occurring among RISK11-negative participants were due to reactivation or new M tuberculosis infection. We infer that a prognostic test with optimal short-term performance might be useful in identifying people who would benefit from an efficacious intervention in a low-incidence setting, in which the timing of M tuberculosis exposure is often known and subsequent exposure is unlikely.
The 3HP regimen was previously shown to be as effective as 9 months of isoniazid in preventing tuberculosis among individuals with known exposure or positive TST.21 Ethical equipoise of the intervention and control groups in this trial was based on the fact that RISK11 had been validated in selected case-control studies, which can overestimate biomarker performance, and thus risk for tuberculosis among RISK11-positive individuals needed to be tested prospectively in the field. Furthermore, although TPT is given commonly to IFNγ release assay-positive and tuberculin skin test-positive individuals, and individuals with known household exposure to a tuberculosis patient, the vast majority do not progress to tuberculosis disease if left untreated. The risk–benefit balance of 3HP preventive therapy for RISK11-positive individuals was unknown. However, we found no evidence that 3HP treatment reduced the rate of incident tuberculosis over 15 months in RISK11-positive individuals, who might be further advanced along the spectrum of tuberculosis pathogenesis.19 Interpretation of the results is limited by the wide CIs. It is also notable that no tuberculosis cases were observed in fully adherent participants through 9 months. This finding is consistent with the possibility that 3HP was sufficient to temporarily halt, but insufficient to sterilise, incipient tuberculosis, resulting in reactivation. A RISK11-targeted preventive therapy strategy for high tuberculosis transmission settings like South Africa might require a more potent therapeutic regimen than 3HP. 3HP might have been sufficient to sterilise incipient tuberculosis disease, but not to protect against tuberculosis disease resulting from reinfection after completion of the treatment course. Although it is not possible to distinguish between reactivation and reinfection tuberculosis cases in this study, we suggest that the limited time available for reinfection and subsequent progression to disease after completing 3HP makes the latter possibility less likely.
The study was subject to a number of limitations. The hybrid design required an open-label treatment group,2 with no placebo for RISK11-positive participants, so that risk for tuberculosis could also be evaluated in the control group while concealing RISK11 status from participants, site staff, and tuberculosis endpoint laboratory staff for analysis of biomarker performance. Tuberculosis case accrual during the latter stages of follow-up suggested no evidence of ascertainment bias during treatment. Extensive study simulations were done to inform the size of each group for the coprimary analyses. However, due to lower than expected prevalence of RISK11-positive status in the screened population (9·3% vs 15%), enrolment of 1139 RISK11-positive individuals required 2 years, compared with planned enrolment of 1500 RISK11-positive individuals over 1 year. As a result, fewer than expected incident tuberculosis outcomes were observed (24 vs 40 primary endpoints), which might have reduced power for both treatment efficacy and RISK11 performance analyses. Not all participants in the treatment group completed 3HP per protocol, because study drug was discontinued for suspected hypersensitivity reactions or influenza-like illnesses. However, the discontinuation rate (7·5%) was comparable to other trials of 3HP, in which study drug was discontinued in 17·9% of participants overall and in 4·9% due to an adverse event.21 The loss to follow-up rate in this trial (14·4%) was higher than expected and might reflect the challenges of retaining the study participants, in the absence of traditional tuberculosis risk factors for which surveillance is routine. However, loss to follow-up occurred predominantly after the treatment period and did not seem to have been biased by treatment factors. We note that median duration of participation was 13·9 months and thus loss to follow-up did not have major unforeseen effect on statistical power. Strengths of the study include enrolment in geographically distinct sites across South Africa that were representative of populations with different rates of IFNγ release assay positivity and tuberculosis disease, which were congruent with local rates of RISK11 positivity, although the sample size was not sufficient for analysis of signature performance or 3HP efficacy at site level. The findings broadly reflect the South African tuberculosis epidemic, but might not be directly applicable to countries with much lower tuberculosis incidence.
It is not yet known whether other parsimonious tuberculosis signatures, developed and validated like RISK11 in carefully curated case-control studies, will exhibit similar performance characteristics when prospectively tested in the field, where undiagnosed subclinical tuberculosis might pose a challenge to diagnostic performance. Head-to-head analyses of several transcriptomic tuberculosis signatures with promising diagnostic performance are currently underway on CORTIS samples and novel near-patient testing platforms are in development, which might bring cost-effective, community-based tuberculosis biomarker screening closer to implementation in the field. However, although we have shown that a strategy of biomarker-guided tuberculosis preventive therapy is feasible, the optimal preventive therapy regimen for use in such a strategy remains elusive.
Data sharing
Deidentified RISK11 signature scores and primary tuberculosis endpoint data from all participants will be available with publication. The dataset is deposited in Zivahub (https://doi.org/10.25375/uct.13573337.v1), an open access data repository hosted by the University of Cape Town's institutional data repository powered by Figshare for Institutions.
Supplementary Material
Supplementary appendix
Acknowledgments
The trial was funded by the Bill & Melinda Gates Foundation (OPP1116632, OPP1137034) and the Strategic Health Innovation Partnerships Unit of the South African Medical Research Council with funds received from the South African Department of Science and Technology. Rifapentine was donated by the manufacturer (Sanofi). The authors thank the members of the data and safety monitoring board and the trial steering committee.
Contributors
TJS, AF-G, AP-N, SS, GW, KN, GC, and MH designed the study. CI, WB, AH, STM, RH-M, MT, GW, KN, and GC recruited and evaluated participants. TJS, AP-N, SKM, SCM, KH, MM, NB, ME, LJ, and RR collected and analysed laboratory data. AF-G, and BB accessed and verified the data. TJS, AF-G, AP-N, HM, BB, TS, RGW, and MH analysed data and interpreted results. KH, CH, and MK provided operational support. TJS, AF-G, HM, and MH drafted the Article. All authors had full access to the data, and reviewed, revised and gave final approval of the Article before submission.
The CORTIS-01 Study Team
Kesenogile Baepanye, Tshepiso Baepanye, Ken Clarke, Marelize Collignon, Audrey Dlamini, Candice Eyre, Tebogo Feni, Moogo Fikizolo, Phinda Galane, Thelma Goliath, Alia Gangat, Shirley Malefo-Grootboom, Elba Janse van Rensburg, Bonita Janse van Rensburg, Sophy Kekana, Marietjie Zietsman, Adrianne Kock, Israel Kunene, Aneessa Lakhi, Nondumiso Langa, Hilda Ledwaba, Marillyn Luphoko, Immaculate Mabasa, Dorah Mabe, Nkosinathi Mabuza, Molly Majola, Mantai Makhetha, Mpho Makoanyane, Blossom Makhubalo, Vernon Malay, Juanita Market, Selvy Matshego, Nontsikelelo Mbipa, Tsiamo Mmotsa, Sylvester Modipa, Samuel Mopati, Palesa Moswegu, Primrose Mothaga, Dorothy Muller, Grace Nchwe, Maryna Nel, Lindiwe Nhlangulela, Bantubonke Ntamo, Lawerence Ntoahae, Tedrius Ntshauba, Nomsa Sanyaka, Letlhogonolo Seabela, Pearl Selepe, Melissa Senne, MG Serake, Maria Thlapi, Vincent Tshikovhi, Lebogang Tswaile, Amanda van Aswegen, Lungile Mbata, Constance Takavamanya, Pedro Pinho, John Mdlulu, Marthinette Taljaard, Naydene Slabbert, Sharfuddin Sayed, Tanya Nielson, Melissa Senne, Ni Ni Sein, Lungile Mbata (The Aurum Institute); Dhineshree Govender, Tilagavathy Chinappa, Mbali Ignatia Zulu, Nonhle Bridgette Maphanga, Senzo Ralph Hlathi, Goodness Khanyisile Gumede, Thandiwe Yvonne Shezi, Jabulisiwe Lethabo Maphanga, Zandile Patrica Jali, Thobelani Cwele, Nonhlanhla Zanele Elsie Gwamanda, Celaphiwe Dlamini, Zibuyile Phindile Penlee Sing, Ntombozuko Gloria Ntanjana, Sphelele Simo Nzimande, Siyabonga Mbatha, Bhavna Maharaj, Atika Moosa, Cara-Mia Corris (Centre for the AIDS Programme of Research in South Africa); Fazlin Kafaar, Marwou De Kock, Hennie Geldenhuys, Angelique Kany Kany Luabeya, Justin Shenje, Natasja Botes, Susan Rossouw, Hadn Africa, Bongani Diamond, Samentra Braaf, Sonia Stryers, Alida Carstens, Ruwiyda Jansen, Simbarashe Mabwe, Roxane Herling, Ashley Veldsman, Lebohgang Makhete, Marcia Steyn, Sivuyile Buhlungu, Margareth Erasmus, Ilse Davids, Patiswa Plaatjie, Alessandro Companie, Frances Ratangee, Helen Veldtsman, Christel Petersen, Charmaine Abrahams, Miriam Moses, Xoliswa Kelepu, Yolande Gregg, Liticia Swanepoel, Nomsitho Magawu, Nompumelelo Cetywayo, Lauren Mactavie, Habibullah Valley, Elizabeth Filander, Nambitha Nqakala, Angelique Mouton, Fajwa Opperman, Elma Van Rooyen, Petrus Tyambetyu (South African Tuberculosis Vaccine Initiative, University of Cape Town); Elizna Maasdorp, Justine Khoury, Belinda Kriel, Bronwyn Smith, Liesel Muller, Susanne Tonsing, Andre Loxton, Andriette Hiemstra, Petri Ahlers, Marika Flinn (DST/NRF Centre of Excellence for Biomedical TB Research and SAMRC Centre for TB Research, Stellenbosch University); and Eva Chung, Michelle Chung, Alicia Sato (Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Research Center)
Declaration of interests
TJS has a patent of the RISK11 signature pending and reports grants from the Bill and Melinda Gates Foundation and South African Medical Research Council. KN reports grants from CAPRISA. GW reports a patent (PCT/IB2019/052043) pending to University of Cape Town, Stellenbosch University, Max-Planck-Gesellschaft Zur Foerderung Der Wissenschaften EV, Seattle Children's Hospital Doing Business as Seattle Children's Research Institute, and UK Research and Innovation. GC reports grants from the Bill & Melinda Gates Foundation. AP-N has a patent of the RISK11 signature pending and reports grants from the Bill & Melinda Gates Foundation and the South African Medical Research Council. MH reports grants from the Bill & Melinda Gates Foundation and the South African Medical Research Council. | 25 MILLIGRAM, ONCE WEEKLY | DrugDosageText | CC BY | 33508224 | 20,168,180 | 2021-03 |
What was the dosage of drug 'RIFAPENTINE'? | Biomarker-guided tuberculosis preventive therapy (CORTIS): a randomised controlled trial.
Targeted preventive therapy for individuals at highest risk of incident tuberculosis might impact the epidemic by interrupting transmission. We tested performance of a transcriptomic signature of tuberculosis (RISK11) and efficacy of signature-guided preventive therapy in parallel, using a hybrid three-group study design.
Adult volunteers aged 18-59 years were recruited at five geographically distinct communities in South Africa. Whole blood was sampled for RISK11 by quantitative RT-PCR assay from eligible volunteers without HIV, recent previous tuberculosis (ie, <3 years before screening), or comorbidities at screening. RISK11-positive participants were block randomised (1:2; block size 15) to once-weekly, directly-observed, open-label isoniazid and rifapentine for 12 weeks (ie, RISK11 positive and 3HP positive), or no treatment (ie, RISK11 positive and 3HP negative). A subset of eligible RISK11-negative volunteers were randomly assigned to no treatment (ie, RISK11 negative and 3HP negative). Diagnostic discrimination of prevalent tuberculosis was tested in all participants at baseline. Thereafter, prognostic discrimination of incident tuberculosis was tested in the untreated RISK11-positive versus RISK11-negative groups, and treatment efficacy in the 3HP-treated versus untreated RISK11-positive groups, during active surveillance through 15 months. The primary endpoint was microbiologically confirmed pulmonary tuberculosis. The primary outcome measures were risk ratio [RR] for tuberculosis of RISK11-positive to RISK11-negative participants, and treatment efficacy. This trial is registered with ClinicalTrials.gov, NCT02735590.
20 207 volunteers were screened, and 2923 participants were enrolled, including RISK11-positive participants randomly assigned to 3HP (n=375) or no 3HP (n=764), and 1784 RISK11-negative participants. Cumulative probability of prevalent or incident tuberculosis disease was 0·066 (95% CI 0·049 to 0·084) in RISK11-positive (3HP negative) participants and 0·018 (0·011 to 0·025) in RISK11-negative participants (RR 3·69, 95% CI 2·25-6·05) over 15 months. Tuberculosis prevalence was 47 (4·1%) of 1139 versus 14 (0·78%) of 1984 in RISK11-positive compared with RISK11-negative participants, respectively (diagnostic RR 5·13, 95% CI 2·93 to 9·43). Tuberculosis incidence over 15 months was 2·09 (95% CI 0·97 to 3·19) vs 0·80 (0·30 to 1·30) per 100 person years in RISK11-positive (3HP-negative) participants compared with RISK11-negative participants (cumulative incidence ratio 2·6, 95% CI 1·2 to 5·9). Serious adverse events related to 3HP included one hospitalisation for seizures (unintentional isoniazid overdose) and one death of unknown cause (possibly temporally related). Tuberculosis incidence over 15 months was 1·94 (95% CI 0·35 to 3·50) versus 2·09 (95% CI 0·97 to 3·19) per 100 person-years in 3HP-treated RISK11-positive participants compared with untreated RISK11-positive participants (efficacy 7·0%, 95% CI -145 to 65).
The RISK11 signature discriminated between individuals with prevalent tuberculosis, or progression to incident tuberculosis, and individuals who remained healthy, but provision of 3HP to signature-positive individuals after exclusion of baseline disease did not reduce progression to tuberculosis over 15 months.
Bill and Melinda Gates Foundation, South African Medical Research Council.
Introduction
Large-scale prevention of progression from Mycobacterium tuberculosis infection to tuberculosis disease is key to achieving WHO End TB Strategy targets, yet tuberculin skin tests (TST) and interferon (IFN) γ release assays have poor specificity for incident tuberculosis.1 A biomarker-targeted prevention strategy using a highly specific correlate of risk (COR) for incident tuberculosis, in tandem with effective short-course tuberculosis preventive therapy (TPT),2 might impact the epidemic by preventing incident tuberculosis disease before transmission.3 Modelling suggests a three-times reduction in burden of TPT if targeted by COR, compared with IFNγ release assays and TST.4 Furthermore, because active tuberculosis disease should be excluded before starting TPT, additional utility of the prognostic COR as a screening (triage) test to identify undiagnosed tuberculosis disease would allow earlier curative treatment. WHO and FIND have developed target product profiles (TPP) for triage tests for tuberculosis (optimal and minimum sensitivity of >95% and >90%, and specificity of >80% and >70%, respectively),5 and incipient tuberculosis tests (minimum sensitivity and specificity of 75% and 75%, and optimal sensitivity and specificity of 90% and 90%, respectively).6
Research in context
Evidence before this study
Host blood RNA signatures have potential as tuberculosis triage or diagnostic tests, and as predictive tests to target tuberculosis preventive therapy. We searched MEDLINE, Scopus, Web of Science, and EBSCO libraries for publications between Jan 1, 2005, and May 31, 2020, using the search terms “Tuberculosis” OR “TB” OR “Mycobacterium tuberculosis” OR “MTB” AND “diagnosis” OR “diagnostic” OR “detect” OR “predic”OR “prognosis” OR “prognostic” OR “screen” AND “Blood Biomarker” OR “blood biomarkers” OR “bio-signature” OR “gene expression” OR “genetic transcription” OR “host blood” OR “immune marker” OR “immunologic marker” OR “Ribonucleic Acid” OR “RNA” OR “signature” OR “surrogate endpoint” OR “surrogate marker” OR “transcriptome” OR “transcriptomic” AND “Area under curve” OR “AUC” OR “receiver operating characteristic” OR “ROC” OR “Accuracy” OR “Performance” OR “sensitivity” OR “specificity”. Studies comparing blood RNA signatures in individuals with tuberculosis versus Mycobacterium tuberculosis-uninfected controls, individuals with other respiratory diseases, or with M tuberculosis infection and using a microbiological reference standard of either sputum M tuberculosis culture, Xpert MTB/RIF, or smear microscopy for tuberculosis diagnosis, were included.
28 studies reported evaluation of 32 host blood RNA signatures for diagnosis or prediction of progression to tuberculosis disease in 83 cohorts. Only two studies prospectively tested performance of an RNA signature in all evaluable participants; the remainder used a case-control design. Multiple studies have tested tuberculosis preventive therapy in people with M tuberculosis latent tuberculosis infection. No studies have tested efficacy of tuberculosis preventive therapy to avert disease in RNA signature-positive people.
Added value of this study
This large randomised, controlled trial in five South African communities prospectively tested diagnostic and prognostic performance of an RNA signature (RISK11) in all evaluable participants, and estimated efficacy of tuberculosis preventive therapy to avert disease in RNA signature-positive people. More than 1% of HIV-uninfected community volunteers had previously undiagnosed, microbiologically confirmed tuberculosis at screening, more than 80% of which was asymptomatic. RISK11 showed moderate performance for tuberculosis triage, but good performance for diagnosis of symptomatic tuberculosis, and for short-term prediction of incident tuberculosis. 3 months of once-weekly, high-dose isoniazid and rifapentine (3HP) did not reduce incident disease in RISK11-positive individuals over 15 months of follow-up.
Implications of all the available evidence
Host blood biomarker development must consider that subclinical tuberculosis might be characterised by more heterogenous, or less pronounced blood inflammatory responses than symptomatic tuberculosis, or both, which will affect RNA signature performance. RISK11 might be better suited to screening of symptomatic individuals with possible tuberculosis than for mass community-based screening. RISK11 can identify those at highest risk for short-term progression to disease, but a more potent regimen than 3HP might be needed to prevent tuberculosis in RISK11-positive individuals.
We previously developed a 16-gene transcriptomic signature by whole blood RNA sequencing for identification of individuals at high risk of developing tuberculosis (the Zak16 signature).7, 8 Measurement of Zak16 was adapted to quantitative RT-PCR (RT-qPCR), and predictive ability for incident tuberculosis was validated in an independent longitudinal cohort of household contacts of tuberculosis patients.8 We reduced this signature to 11 genes (RISK11) with equivalent performance,9, 10 to allow testing in 96-well PCR format. Zak16 and RISK11 also did well as non-sputum screening tests for prevalent, active tuberculosis in case-control studies, measured by RNA sequencing, microarray,7, 8 or microfluidic RT-qPCR.9, 10 In a 2020 systematic review and patient-level pooled meta-analysis of 17 transcriptomic signatures for prognosis of incident tuberculosis, Zak16 was among eight signatures that achieved a positive predictive value above the WHO TPP benchmark for incipient tuberculosis tests.11 Since case-control studies might overestimate performance characteristics, testing in unselected populations is needed.
We report on a randomised controlled trial (CORTIS; NCT02735590), which prospectively measured diagnostic and prognostic performance of RISK11 for triage of prevalent and prediction of incident tuberculosis in South African adults; and, in parallel, estimated efficacy of short-course TPT to avert incident disease in RISK11-positive individuals.
Methods
Study design
This randomised controlled trial used a hybrid treatment selection, three-group study design to evaluate efficacy of the intervention and, in parallel, performance of the biomarker used to allocate that intervention (figure 1).2 The coprimary aims were to test, over 15 months, whether RISK11 status differentiates between people with and without cumulative prevalent or incident tuberculosis; and whether preventive therapy (weekly high-dose isoniazid and rifapentine for 12 weeks [3HP]) reduces tuberculosis incidence among RISK11-positive people compared with active surveillance only. RISK11 performance to detect prevalent tuberculosis was evaluated in all groups at baseline. RISK11 performance to predict incident tuberculosis was evaluated in the untreated RISK11-positive and RISK11-negative groups, and treatment efficacy was estimated from the 3HP treated and untreated RISK11-positive groups, after omitting participants with baseline tuberculosis. Efficiency of the hybrid study design was maximised by using the RISK11-positive and 3HP-negative group to evaluate both biomarker performance and treatment efficacy.Figure 1 Study design
The prevalence of RISK11 positivity was not precisely known in the study population; therefore, the number of individuals to be screened and the randomisation of RISK11-negative participants to enrolment was monitored and adjusted adaptively to ensure concurrent enrolment of the target number of RISK11-positive and RISK11-negative participants, per protocol specifications. The study used a three-group design to evaluate efficacy of the intervention and, in parallel, performance of the biomarker used to allocate that intervention. Diagnostic performance for differentiation of prevalent tuberculosis was tested in all three groups at baseline; prognostic performance for differentiation of incident tuberculosis over 15 months was tested in the two untreated groups (untreated RISK11 positive and untreated RISK11 negative); and treatment efficacy of 3HP over 15 months was tested in the two RISK11-positive groups (treated and untreated RISK11 positive). *Participants evaluated for eligibility at screening and enrolment. †Groups randomly assigned in blocks to ensure concurrent enrolment.
Routine implementation of TPT requires that patients are screened to exclude prevalent tuberculosis before TPT is provided to prevent incident disease. Therefore, because risk for prevalent and incident tuberculosis by RISK11 status must be understood before efficacy of preventive therapy against incident tuberculosis in RISK11-positive people can be interpreted, these secondary analyses are presented before the primary analysis of treatment efficacy.
The trial protocol (appendix p 21) was approved by the South African Health Products Regulatory Agency (20160305) by the Institutional Human Ethics Committees of participating sites; and was registered on ClinicalTrials.gov (NCT02735590). All participants provided written informed consent in their language of choice.
Participants
Adult volunteers living in tuberculosis-endemic communities in South Africa were recruited at five sites (South African Tuberculosis Vaccine Initiative, Worcester; Immunology Research Group, Stellenbosch University, Ravensmead; Aurum Institute, Klerksdorp and Rustenberg; and Centre for the AIDS Programme of Research in South Africa, Durban). Community-based recruitment was by word-of-mouth, house-to-house visits, and liaison with non-governmental organisations. Recruitment did not target groups at high risk of tuberculosis, such as household contacts. Eligible participants were aged between 18 years and 59 years, HIV-negative, without a history of tuberculosis disease in the last 3 years or preselected comorbidities (appendix p 8).
Screening
Venous blood was collected in PAXgene RNA tubes from all potentially eligible people at screening, frozen at −20°C, and shipped weekly to the South African Tuberculosis Vaccine Initiative Immunology Laboratory for RISK11 testing by qRT-PCR assay. Participants with a RISK11 score of at least 60% were classified a priori as RISK11 positive and less than 60% as RISK11 negative. This 60% threshold was the optimal point at which sensitivity and specificity for prognosis of incident tuberculosis were balanced in case-control studies.2 Samples with failed reference primer-probe reactions, with marked deviation in internal positive control sample from historical runs, or more than 30% failed interferon-stimulated genes primer-probe reactions (see quality control criteria and analysis script in Bitbucket instance) were classified as indeterminate. Per-participant qualitative results (RISK11 positive and RISK11 negative) were provided to the Triclinium Clinical Development (TCD) Data Centre for participant randomisation (see appendix pp 2–3).
Randomisation and masking
Assignment to study group was managed by an unmasked randomisation team from the TCD Data Centre, based on RISK11 status. RISK11-positive volunteers were randomly assigned (1:2; block size 15) to either open-label 3HP (3HP-positive group), or active tuberculosis surveillance without 3HP (3HP-negative group), in accordance with a randomisation schedule generated using SAS, version 9.4. RISK11-negative volunteers were concurrently randomly assigned either to active tuberculosis surveillance (3HP-negative group) or to non-participation, to enrich the study population for RISK11-positive participants.
Study group allocation was revealed to site staff after enrolment of eligible participants within 28 days of screening. The 3HP-negative group was double-blinded to RISK11 status, but unblinded to treatment allocation; the 3HP-positive group was unblinded to both RISK11-positive status and treatment allocation (figure 1). RISK11-positive participants randomly assigned to active surveillance did not receive a placebo, to maintain blinding of participants and study team members to RISK11 status.
Procedures
Target enrolment was maximally 3200 participants (1500 RISK11 positive and 1700 RISK11 negative). The randomisation ratio for RISK11-negative volunteers was adapted to ensure concurrent enrolment of the recruitment target. Adaptations occurred at intervals, informed by 3-monthly operational monitoring reports based on enrolment rate, RISK11-positive and RISK11-negative prevalence, and tuberculosis case accrual blinded to RISK11 status (appendix p 7).
Enrolment procedures included phlebotomy for IFNγ release assays (QuantiFERON TB Gold-Plus, Qiagen), tuberculosis symptom screen (a positive tuberculosis symptom screen included one or more symptoms of persistent unexplained cough, fever, night sweats, weight loss, or any haemoptysis), and collection of two spontaneous expectorated sputum samples for Xpert MTB/RIF assay (Cepheid) from all sputum-productive participants, regardless of symptoms.
All participants attended up to seven study visits, including four study site visits at months 3, 6, 12, and 15 (end of study), and three telephonic contact or field visits at months 1, 2, and 9. HIV testing was repeated at months 6 and 12.
Participants in the 3HP group received open-label, high-dose isoniazid (15 mg/kg; maximum dose 900 mg) with pyridoxine supplementation (25 mg) and rifapentine based on body weight (>32–50 kg, 750 mg; >50 kg, 900 mg), given weekly as directly observed oral doses, ideally with food, over 12 weeks. Completion of 3HP treatment was defined as receipt of 11 doses within 16 weeks (appendix p 3).
Outcomes
The two primary outcome measures were RISK11-positive to RISK11-negative risk ratio (RR) for prevalent or incident tuberculosis disease, and 3HP treatment efficacy through 15 months. Diagnostic performance for prevalent tuberculosis was evaluated on the presence of tuberculosis at the enrolment visit within the ITT cohort.
Participants in the 3HP group had each dose directly observed by study staff, and attended clinic for evaluation of solicited adverse events and possible adverse events of special interest at weeks 1–11. Solicited adverse events included gastrointestinal signs and symptoms suggestive of hepatotoxicity, such as nausea, vomiting, and jaundice. Possible hypersensitivity reactions, including influenza-like illness, were reported as adverse events of special interest. Safety events meeting the definition for a serious adverse event, whether deemed related or unrelated to study drug, were reported for both all participants through end of study.
Statistical analysis
The intention-to-treat (ITT) cohort included all enrolled participants who completed investigation for tuberculosis endpoints at baseline. The modified intention-to-treat (mITT) cohort included all participants in the ITT population who completed at least one post-baseline tuberculosis endpoint investigation and omitted participants with endpoint-defined tuberculosis disease at baseline (prevalent tuberculosis).
The diagnostic RR was estimated as a proportion of participants with tuberculosis disease among RISK11-positive divided by RISK11-negative participants. Prognostic performance for incident tuberculosis after enrolment was evaluated among 3HP-negative participants within the mITT cohort (ie, excluding participants with tuberculosis at baseline). Prognostic RR was estimated as the cumulative incidence through 15 months for RISK11-positive divided by RISK11-negative participants. The primary RR was an estimate of the probability of having prevalent tuberculosis or developing incident tuberculosis among RISK11-positive divided by RISK11-negative participants; this combined probability of prevalent and incident tuberculosis was computed for each group as the probability of prevalent tuberculosis plus the probability of incident tuberculosis through 15 months (conditioned on not having prevalent tuberculosis). Efficacy of 3HP preventive therapy to reduce the rate of incident tuberculosis disease compared with the untreated RISK11-positive participants was also evaluated in the mITT population. Treatment efficacy was estimated as one minus the cumulative incidence of RISK11-positive and 3HP-positive participants divided by RISK11-positive and 3HP-negative participants through 15 months. A per-protocol analysis of treatment efficacy was done and excluded RISK11-positive and 3HP-positive participants that received less than 11 of the 12 weekly doses of 3HP.
For statistical efficiency, a random subset of RISK11-negative participants were enrolled, therefore creating an ITT cohort artificially enriched with RISK11-positive participants. Therefore, unless stated otherwise, all analyses were adjusted so that results reflected the screened population. Secondary performance metrics such as sensitivity and specificity were estimated using standard formulas with binary endpoints; a percentile bootstrap with 20 000 samples was used to estimate 95% CIs. For descriptive analyses (Table 1, Table 2), rank-based Wilcoxon rank-sum tests were used to compare continuous variables in RISK11-positive versus RISK11-negative groups. Fisher's exact test was used to compare binary readouts; p values in Table 1, Table 2 were not adjusted for multiple comparisons. The prespecified statistical analysis plan is included in the appendix (p 82) and contains detailed description of the statistical methods.Table 1 Baseline characteristics and primary tuberculosis endpoints by group
Total (n=2923) RISK11 positive and 3HP positive (n=375) RISK11 positive and 3HP negative (n=764) RISK11 negative (n=1784) RISK11 positive vs RISK11 negative, p value*
Sex
Female 1585 (54·2%) 213 (56·8%) 469 (61·4%) 903 (50·6%) <0·001
Male 1338 (45·8%) 162 (43·2%) 295 (38·6%) 881 (49·4%) ..
Age, years 28·5 (9·0) 28·8 (9·5) 28·4 (9·2) 28·4 (8·7) 0·541
Race or ethnicity
Asian 4 (0·1%) 0 1 (0·1%) 3 (0·2%) 0·567
Black African 1947 (66·6%) 227 (60·5%) 477 (62·4%) 1243 (69·7%) <0·001
White 4 (0·1%) 0 1 (0·1%) 3 (0·2%) 0·567
Mixed race 968 (33·1%) 148 (39·5%) 285 (37·3%) 535 (30·0%) <0·001
Body-mass index, kg/m2 24·6 (7·7) 24·1 (6·3) 24·4 (6·1) 24·9 (8·6) 0·354
Previous tuberculosis 230 (7·9%) 36 (9·6%) 75 (9·8%) 119 (6·7%) 0·003
Smoking 1478 (50·6%) 203 (54·1%) 391 (51·2%) 884 (49·6%) 0·170
Family tuberculosis history 462 (15·8%) 66 (17·6%) 110 (14·4%) 286 (16·0%) 0·675
Interferon γ release assay positive 1895 (64·8%) 250 (66·7%) 528 (69·1%) 1117 (62·6%) <0·001
Follow-up, months 15 (9·4–15·0) 15 (11·1–15·0) 15 (9·1–15·0) 13·6 (9·4–15·0) 0·056
Prevalent tuberculosis, n (probability, 95% CI) 61 (1·1%, 0·77–1·6)† 47 (4·1%, 3·1–5·4)‡ 47 (4·1%, 3·1–5·4)§ 14 (0·78%, 0·47–1·3) NA
Incident tuberculosis, n (cases per 100 person years, 95% CI) 24 (1·05, 0·59–1·5)§ 6 (1·9, 0·35–3·5) 14 (2·09, 0·97–3·19) 10 (0·80, 0·30–1·30) NA
Cumulative tuberculosis, n (probability, 95% CI)¶ 85 (0·022, 0·016–0·028)† 61 (0·066, 0·049–0·084)‖** 61 (0·066, 0·049–0·084)** 24 (0·018, 0·011–0·026) NA
Data are n (%), mean (SD), or median (IQR), unless stated otherwise. Secondary tuberculosis endpoints by group are in the appendix (p 13). NA=not applicable.
* For continuous data, p values from Wilcoxon rank sum test. For categorical data, p values from Fischer's exact test.
† Overall rate estimates are weighted combinations of the enrolled participants to reflect the screened population.
‡ Overall incidence and cumulative tuberculosis excludes RISK11-positive and 3HP-positive incident cases.
§ Prevalent tuberculosis among RISK11 positive was assessed by combining the 3HP-negative and 3HP-positive groups. Value is repeated for RISK11 positive and 3HP positive, and RISK11 positive and 3HP negative.
¶ Probability of observing prevalent or incident tuberculosis over 15 months.
‖ Probability of prevalent or incident tuberculosis not estimated for RISK11-positive and 3HP-positive because it would combine data from before and after 3HP treatment and is therefore potentially misleading.
** Estimate for RISK11 positive includes 3HP-positive prevalent cases and 3HP-negative prevalent and incident cases. Value is repeated for RISK11 positive and 3HP positive, and RISK11 positive and 3HP negative.
Table 2 Performance of RISK11 and IGRA for prevalent and incident tuberculosis
Prevalent tuberculosis (ITT cohort) Incident tuberculosis (mITT cohort)*
RISK11 (60)† RISK11 (26)† IGRA RISK11 (60)† RISK11 (26)† IGRA
Risk ratio 5·13 (2·93 to 9·43) 7·39 (3·46 to 25·69) 4·43 (1·93 to 14·18) 2·61 (1·15 to 5·94) 2·67 (1·04 to 8·66) 2·83 (0·95 to 99·79)
Biomarker prevalence 9·2% (9·2 to 9·2) 25·8% (24·1 to 27·4) 63·4% (61·3 to 65·4) 9·0% (9·0 to 9·0) 25·3% (23·7 to 26·9) 63·2% (61·1 to 65·3)
AUC‡ 0·77 (0·68 to 0·86) .. 0·66 (0·58 to 0·73) 0·63 (0·47 to 0·80) .. 0·67 (0·54 to 0·79)
Sensitivity 34·9% (23·7 to 52·2) 72·1% (54·5 to 90·2) 88·7% (77·1 to 96·4) 25·0% (12·7 to 45·9) 47·5% (25·9 to 75·0) 83·2% (61·9 to 100·0)
Specificity 91·0% (90·9 to 91·1) 74·7% (73·1 to 76·4) 36·9% (34·9 to 39·0) 91·1% (91·0 to 91·2) 74·9% (73·2 to 76·5) 37·0% (34·9 to 39·1)
PPV§ 4·1% (3·0 to 5·4) 3·1% (2·0 to 4·3) 1·5% (1·0 to 2·2) 1·9% (0·9 to 3·0) 1·3% (0·6 to 2·1) 0·9% (0·5 to 1·4)
PPV (2% incidence)¶ .. .. .. 6·7% (3·5 to 11·8) 4·6% (2·5 to 7·1) 3·3% (2·5 to 3·9)
NPV§ 99·2% (98·8 to 99·6) 99·6% (99·2 to 99·9) 99·7% (99·3 to 99·9) 99·4% (99·0 to 99·8) 99·5% (99·1 to 99·9) 99·7% (99·2 to 100·0)
NPV (2% incidence)¶ .. .. .. 97·9% (97·6 to 98·5) 98·2% (97·5 to 99·2) 98·8% (97·4 to 100·0)
NNS or NNT‖ 29·9 (21·8 to 46·6) 37·8 (25·5 to 65·7) 83·1 (53·2 to 179·8) 75·1 (40·4 to 277·5) 123·8 (47·2 to 834·1) 168 (−440 to 1059)
Data are risk ratio (95 %CI), % (95% CI), AUC (95% CI), or NNS or NNT (95% CI). ITT=intention to treat. mITT=modified intention-to-treat. IGRA=interferon γ release assay. AUC=area under the receiver operating characteristic curve. PPV=positive predictive value. NPV=negative predictive value. NNS=number needed to screen. NNT=number needed to treat.
* Computed over 15-month prognostic window. Performance of RISK11 and IGRA for incident tuberculosis over 6-month and 12-month prognostic windows is in the appendix (p 16).
† RISK11 score threshold at 60% or 26%.
‡ AUC is computed across all score thresholds and value is presented under RISK11 (60).
§ Computed using the prevalence and incidence rates in the trial population as appropriate.
¶ Computed assuming 2% annual incidence of tuberculosis in the population.
‖ NNS for prevalent tuberculosis; NNT for incident tuberculosis. Performance of RISK11 and IGRA for prevalent and incident tuberculosis based on secondary endpoint (≥1 sample+) is in the appendix (p 15).
The study was designed to have 90% power to reject the null hypothesis of a RISK11-positive and RISK11-negative cumulative risk ratio less than 2 with one-sided alpha of 0·025. For treatment efficacy there was 80% power to reject the null hypothesis of efficacy less than 20%, with one-sided alpha of 0·05 and under the alternative design hypothesis that efficacy was 80%. To compute statistical power for these aims, a stochastic simulation of the trial was constructed, based on which we expected to observe 33 tuberculosis disease endpoints among 1500 RISK11-positive participants and seven tuberculosis disease endpoints among 1700 RISK11-negative participants (appendix p 6).
Role of the funding source
The trial was funded by the Bill & Melinda Gates Foundation (OPP1116632, OPP1137034) and the Strategic Health Innovation Partnerships Unit of the South African Medical Research Council, with funds received from the South African Department of Science and Technology. The Gates Foundation contributed to the study design. The regulatory sponsor was the University of Cape Town. Rifapentine (PRIFTIN) was donated by the manufacturer (Sanofi), who had no role in the design, implementation, analysis, or reporting of the trial. All authors had access to all the data reported in the study. The corresponding author had final responsibility for the decision to submit for publication.
Results
Between Sept 20, 2016, and Oct 19, 2018, 20 207 volunteers consented to participation; 16 248 met inclusion criteria at screening and 15 777 with a RISK11 result were potentially eligible for enrolment (figure 2). Of the 20 207 adults assessed for eligibility, common reasons for exclusion included HIV infection (1246 [6·1%]) and comorbid conditions (1369 [6·8%]; appendix p 8). 2923 eligible participants were enrolled after randomisation (1784 [61·0%] RISK11 negative and 1139 [39·0%] RISK11 positive; table 1).Figure 2 Trial profile
ITT=intention to treat. mITT=modified intention to treat. LTFU=lost to follow-up. PP=per protocol analysis. *585 participants did not complete the trial for reasons including: 53 (9%) pregnancies, 22 (4%) investigator withdrawals, 46 (8%) consent withdrawals, 26 (4%) HIV infections, 422 (72%) LTFU, and 16 (3%) deaths.
Participants were enrolled at five geographically diverse sites across South Africa (appendix pp 9–11). Among participants with a RISK11 result, 1434 (9·3%) of 15 494 were RISK11 positive, with the proportion ranging from 6·2% to 13·0% across the five sites. RISK11-positive participants were randomly asigned either to receive treatment (375 [32·9%] RISK11 positive and 3HP positive) or undergo observation without treatment (764 [67·1%] RISK11 positive and 3HP negative).
There were no significant differences in smoking history, family history of tuberculosis, or febrile illness between RISK11-positive and RISK11-negative participants (table 1). A higher proportion of RISK11-positive (75 [9·8%] of 364) than RISK11-negative (119 [6·7%] of 1784) participants reported previous tuberculosis disease (p=0·003). Compared with RISK11 negative participants, a greater proportion of RISK11-positive participants were female and mixed race (p<0·001; table 1).
Median duration of follow-up for incident tuberculosis was 13·9 months (IQR 9·0–15·0) and 1879 (66%) of 2500 3HP-negative mITT participants attended at least six scheduled visits. 1416 (49%) of 2838 participants were followed up for 15 months and 2160 (75%) of 2838 participants were followed up for at least 9 months. 585 (21%) of 2838 participants did not complete the study because of withdrawal, death, or loss to follow-up (figure 2; table 1).
Among 91 participants with tuberculosis who reached the primary endpoint, 61 were diagnosed with prevalent tuberculosis at baseline (47 RISK11 positive and 14 RISK11 negative; table 1; appendix p 13). Prevalence of tuberculosis in RISK11-positive and RISK11-negative participants was 4·1% (95% CI 3·1–5·4) and 0·78% (0·5–1·3), respectively (figure 3). Thereafter, 24 participants in the untreated group were diagnosed with incident tuberculosis disease (14 RISK11 positive and ten RISK11 negative; table 1; appendix p 13) with overall incidence of 1·05 cases (95% CI 0·59–1·5) per 100 person-years.Figure 3 RISK11 detection of combined prevalent and incident tuberculosis and diagnostic performance
(A) Prevalence of tuberculosis in RISK11-positive (47 cases,) and RISK11-negative (14 cases, red bar) participants at trial enrolment. Error bars depict 95% CI. Cumulative incidence probability of tuberculosis in RISK11-positive (14 cases, blue line) or RISK11-negative (10 cases, red line) mITT participants during follow-up. Shaded areas represent 95% CI. (B) Ratio of RISK11-positive versus RISK11 negative cumulative incidence probability of observing prevalent or incident tuberculosis disease, in the ITT population of the observation group. (C) RISK11 signature scores (each dot represents a participant) measured at screening in trial participants, stratified on tuberculosis diagnosis. Boxes depict IQR, midline represents the median, and whiskers indicate range among enrolled participants. (D) RISK11 signature scores measured at screening in prevalent tuberculosis cases with or without any tuberculosis symptoms, in incident tuberculosis cases or those who did not have a tuberculosis diagnosis. The enrolled population, not the screened population, is represented in (C) and (D), because a large fraction of RISK11-negative participants were not enrolled by design. (E) ROC curves depicting RISK11 diagnostic performance for prevalent tuberculosis in the ITT population, for prevalent tuberculosis among individuals with no symptoms of tuberculosis (asymptomatic) and among individuals with at least one symptom consistent with tuberculosis disease (symptomatic). Shaded areas represent the 95% CI. The grey and black dots indicate the minimum and optimal criteria, respectively, set out in the WHO target product profile for a triage test. The empty dot indicates the criteria set out in the WHO target product profile for a confirmatory diagnostic test. TRP=true positive rate. ITT=intention to treat. FPR=false positive rate. AUC=area under the receiver operating characteristic curve.
In the primary analysis of biomarker performance for cumulative tuberculosis, cumulative probability of observing prevalent or incident tuberculosis disease in the ITT population was 0·066 (95% CI 0·049–0·084) in RISK11-positive participants and 0·018 (0·011–0·025) in RISK11-negative participants, with a risk ratio of 3·69 (95% CI 2·25–6·05) over 15 months (figure 3).
A wide range of RISK11 scores was observed, irrespective of tuberculosis outcome (figure 3). Among enrolled participants, those who remained tuberculosis free (controls) had significantly lower RISK11 scores (24·2%, IQR 8·2–75·3) than those with prevalent or incident tuberculosis disease (76·7%, 36·6–94·4; Wilcoxon rank-sum test p<0·0001; figure 3).
In the secondary analysis of biomarker performance for prevalent tuberculosis, using the prespecified RISK11 test threshold (60%) there was 5·13-times (95% CI 3·01–10·69) increased risk of prevalent tuberculosis disease at baseline in RISK11-positive versus RISK11-negative participants, with sensitivity of 35% (95% CI 24–52) and specificity of 91% (95% CI 91–91; table 2). The receiver operating characteristic (ROC) analysis (figure 3) showed that a RISK11 threshold of 26% provided sensitivity of 72% (95% CI 54–90) and specificity of 75% (95% CI 73–76; table 2); with area under the diagnostic ROC curve (AUC) of 0·77 (95% CI 0·68–0·86). These performance estimates did not meet the minimum criteria for a tuberculosis triage test (table 2). 50 (83·6%) of 61 participants with prevalent tuberculosis had no symptoms compatible with tuberculosis disease, and the remaining 11 participants with at least one symptom consistent with tuberculosis had RISK11 scores of more than 80% (median 96%; figure 3; appendix p 14). Discrimination between symptomatic prevalent tuberculosis and symptomatic controls was high (AUC 0·97, 95% CI 0·95–0·99; figure 3) and, with a highly specific threshold, performance exceeded the optimal TPP for a tuberculosis triage test in this population. By contrast, RISK11 discriminated between asymptomatic controls and asymptomatic prevalent tuberculosis cases with an AUC of 0·75 (95% CI 0·66–0·84; figure 3).
In the secondary analysis of biomarker performance for incident tuberculosis, annualised incidence was 2·1 versus 0·8 per 100 person-years among the RISK11-positive versus RISK11-negative participants, respectively, which was equivalent to a 0·026 (95% CI 0·01–0·04) versus 0·010 (0·004–0·02) cumulative incident probability of developing tuberculosis disease over 15 months, respectively (figure 3). No incident tuberculosis cases were detected in RISK11-negative participants until 8·7 months (figure 3). Tuberculosis incidence through 15 months among RISK11-positive participants was 2·61 (95% CI 1·15–5·94) times higher than RISK11-negative participants (table 2); and the RISK11 signature discriminated between incident tuberculosis cases and controls with AUC of 0·63 (95% CI 0·47–0·80; figure 4). Over this period, at the predefined 60% threshold, RISK11 showed very low sensitivity of 25% (95% CI 12–46) with specificity of 91% (95% CI 91–91). At an exploratory RISK11 threshold of 26%, which provided 75% specificity, sensitivity was 47% (95% CI 26–74). By comparison, the prognostic sensitivity of IFNγ release assays over 15 months was 83% (62–100), but more than 60% of the population was IFNγ release assay positive (specificity 37%, 95% CI 35–40; table 2).Figure 4 Prognostic performance of RISK11 and treatment efficacy of 3HP
(A) ROC curve depicting RISK11 prognostic performance for incident tuberculosis through 15 months of follow-up. The shaded area represents 95% CI. The grey and black dots depict the minimum and optimal criteria, respectively, set out in the WHO target product profile for an incipient tuberculosis test. (B) RISK11 performance (area under the ROC curve) for endpoints within a 6-month sliding window from month 0 through 15. The shaded area represents 95% CI. (C) ROC curves depicting RISK11 prognostic performance for incident tuberculosis through expanding follow-up periods. The grey and black dots depict the minimum and optimal criteria, respectively, set out in the WHO target product profile for an incipient tuberculosis test. (D) Cumulative incidence of tuberculosis in RISK11-positive participants who were randomly assigned to 3HP (six cases, red line) and RISK11-positive participants who were randomly assigned to observation (14 cases, blue line) during follow-up. The shaded areas represent 95% CI. (E) Cumulative incidence of tuberculosis in participants who met criteria for treatment adherence per protocol, stratified into RISK11-positive participants who were randomly assigned to 3HP (four cases, red line) and RISK11-positive participants who were randomly assigned to observation (14 cases, blue line) during follow-up. (F) TE estimated through follow-up in participants who met criteria for treatment adherence per protocol. The shaded areas represent 95% CI. TRP=true positive rate. FPR=false positive rate. AUC=area under the receiver operating characteristic curve. TPP=target product profile. TE=treatment efficacy.
RISK11 prognostic performance was highly dependent on time to disease. Instantaneous RISK11 performance, estimated from 6-month sliding windows, showed prognostic discrimination was high (AUC >0·80) for approximately 9 months, before waning towards 0·58 between months 9 and 15 (figure 4; appendix p 16). Prognostic performance of RISK11 for incident tuberculosis within 6 months (AUC 0·95, 95% CI 0·92–1·0) exceeded the optimal TPP for an incipient tuberculosis test (appendix p 16), and for tuberculosis disease within 12 months (0·80, 0·65–0·94; figure 4) approached the minimum TPP (appendix p 16), but over a 15-month period did not meet minimum criteria for a prognostic tuberculosis test (table 2).
In the primary analysis of treatment efficacy among RISK11-positive participants, tuberculosis incidence in the 3HP-positive and 3HP-negative groups was 1·94 cases per 100 person years and 2·09 cases per 100 person years, respectively (figure 4; table 1), with estimated treatment efficacy of 7·0% (95% CI −145 to 64·7) over 15 months. In the subgroup of 286 adherent participants who completed at least 11 doses within 16 weeks, efficacy was 22% (−138 to 74; figure 4) over 15 months. Notably, among adherent participants, there were no tuberculosis cases through 9 months (figure 4).
Adverse events related to 3HP were mostly of mild to moderate severity (appendix p 12). 67 serious adverse events, including 29 due to trauma, occurred in 65 participants. Serious adverse events occurred in 20 (5·3%) of 375 RISK11-positive participants who received 3HP (eight serious adverse events due to trauma), compared with 12 (1·6%) of 764 in RISK11-positive and 3HP-negative participants (Fisher's exact p<0·001). Among RISK11-negative participants, 33 (1·9%) of 1784 experienced serious adverse events. All but two serious adverse events were deemed unrelated to 3HP. Serious adverse events related to 3HP included one hospitalisation for seizures (unintentional isoniazid overdose) and one death of unknown cause (possibly temporally related). One death of unknown cause also occurred in an untreated RISK11-negative participant. There were 16 deaths in total, including five RISK11-positive participants receiving 3HP (three deaths due to trauma), three untreated RISK11-positive participants, and eight RISK11-negative participants.
3HP was halted in 28 (7·5%) of 375 participants, due to an adverse event of special interest (influenza-like illness or other possible hypersensitivity reaction) in 17 (4·5%), hepatotoxicity in one (0·3%), gastrointestinal symptoms in three (0·8%), and seizures in three (0·8%) participants.
RISK11 diagnostic and prognostic performance and treatment efficacy of 3HP based on the secondary endpoint definition (at least one sputum sample; appendix p 14) are described in the appendix (p 15).
Five (8·2%) of the 61 participants witih prevalent tuberculosis were resistant to isoniazid or rifampicin, or both. Two (6·7%) of the 30 participants with incident tuberculosis, both in the untreated group, were resistant to isoniazid and rifampicin. No participants were observed to have drug-resistant incident tuberculosis in the 3HP-positive group.
Discussion
Our goal was to evaluate a biomarker-targeted, community-based strategy to detect missing tuberculosis cases among people who do not seek health care, whose disease might not be detected by symptom-focused screening algorithms, and to prevent disease among those at highest risk of progression to tuberculosis. The RISK11 assay was an effective screening test for active disease in symptomatic participants, in whom performance exceeded the requirements for a triage test, but less so in asymptomatic participants. The RISK11 signature was able to predict risk for tuberculosis disease progression, in a trial population with tuberculosis incidence exceeding one case per 100 person-years, but optimal prognostic performance was limited to a 6-month horizon. While risk-targeted 3HP did not prevent tuberculosis disease over 15 months, there was some evidence of transient efficacy through 9 months among fully adherent participants.
Community-based recruitment of ambulant volunteers was not focused on individuals with known risk factors for tuberculosis, such as household contact. Individuals with recent previous history of tuberculosis (>3 years before screening) and HIV infection were excluded. Nevertheless, more than 1% of study volunteers had previously undiagnosed, microbiologically confirmed tuberculosis at enrolment, based on spontaneous expectorated rather than induced sputum samples. More than 80% of these baseline tuberculosis cases did not have any symptom compatible with tuberculosis disease and would not have been detected by a tuberculosis screening strategy that requires symptoms as the entry point to investigation. This finding is consistent with 46–79% prevalence (median 50%) of subclinical tuberculosis reported in prevalence surveys.12, 13, 14 It is not known whether subclinical tuberculosis would have progressed to symptomatic disease, spontaneously halted, or even reversed if left untreated,15, 16 nor whether subclinical disease directly contributes to M tuberculosis transmission.17 Further research is needed to determine the importance of detection, treatment, and prevention of subclinical disease for global tuberculosis control.
Although very few prevalent tuberculosis cases were symptomatic, RISK11 performance for discrimination of symptomatic prevalent tuberculosis cases from symptomatic controls exceeded the optimal TPP criteria for a triage test, while not meeting the stringent criteria for a confirmatory diagnostic test.5 A 2020 prospective observational study among symptomatic individuals who self-presented to a tuberculosis clinic assessed diagnostic accuracy of 27 transcriptomic signatures for discrimination between prevalent tuberculosis cases and controls.18 The 16-gene Zak signature, from which RISK11 was derived, did not meet the minimum WHO criteria for a triage test, but four of the 27 signatures met these criteria, suggesting that another signature might perform as well as or better than RISK11. RISK11 discrimination of asymptomatic prevalent tuberculosis cases from asymptomatic controls was modest and did not meet the minimal criteria for a triage test. These findings suggest that host blood biomarker development must consider that subclinical tuberculosis might be characterised by more heterogenous or less pronounced peripheral blood inflammatory responses than symptomatic tuberculosis, or both, which affects RNA signature performance. This finding is consistent with lower inflammatory profiles, observed by blood transcriptomic and proteomic analyses, during the subclinical phases of tuberculosis progression compared with subsequent symptomatic, active disease.19, 20 The modest performance characteristics for asymptomatic prevalent tuberculosis would limit applicability of RISK11 for biomarker-targeted, mass community screening in the South African setting, where the majority of baseline tuberculosis cases were subclinical. A host blood biomarker with good sensitivity and specificity for symptomatic tuberculosis might be most useful in countries with low to medium tuberculosis burden, where individuals with compatible symptoms might not otherwise be investigated for tuberculosis. Future diagnostic studies in symptomatic patients seeking health care should also include patients with extrapulmonary and culture-negative tuberculosis, particularly in HIV-infected cohorts, and the full spectrum of differential diagnoses that commonly mimic tuberculosis.
Prognostic performance of RISK11 for risk of progression to incident tuberculosis was poor through 15 months and did not meet the minimum TPP criteria for an incipient tuberculosis test through this prognostic horizon.4 However, good prognostic performance was observed for incident tuberculosis within 12 months of testing and performance exceeded the optimal TPP criteria for tuberculosis occurring within 6 months of testing. The positive predictive value for incident disease (1·9 vs 0·9 for RISK11 compared with IFNγ release assay, respectively) was computed from the observed tuberculosis incidence rate, which was lower than that typically used in estimations (2%).3, 6 It is not possible to determine whether the late incident tuberculosis cases occurring among RISK11-negative participants were due to reactivation or new M tuberculosis infection. We infer that a prognostic test with optimal short-term performance might be useful in identifying people who would benefit from an efficacious intervention in a low-incidence setting, in which the timing of M tuberculosis exposure is often known and subsequent exposure is unlikely.
The 3HP regimen was previously shown to be as effective as 9 months of isoniazid in preventing tuberculosis among individuals with known exposure or positive TST.21 Ethical equipoise of the intervention and control groups in this trial was based on the fact that RISK11 had been validated in selected case-control studies, which can overestimate biomarker performance, and thus risk for tuberculosis among RISK11-positive individuals needed to be tested prospectively in the field. Furthermore, although TPT is given commonly to IFNγ release assay-positive and tuberculin skin test-positive individuals, and individuals with known household exposure to a tuberculosis patient, the vast majority do not progress to tuberculosis disease if left untreated. The risk–benefit balance of 3HP preventive therapy for RISK11-positive individuals was unknown. However, we found no evidence that 3HP treatment reduced the rate of incident tuberculosis over 15 months in RISK11-positive individuals, who might be further advanced along the spectrum of tuberculosis pathogenesis.19 Interpretation of the results is limited by the wide CIs. It is also notable that no tuberculosis cases were observed in fully adherent participants through 9 months. This finding is consistent with the possibility that 3HP was sufficient to temporarily halt, but insufficient to sterilise, incipient tuberculosis, resulting in reactivation. A RISK11-targeted preventive therapy strategy for high tuberculosis transmission settings like South Africa might require a more potent therapeutic regimen than 3HP. 3HP might have been sufficient to sterilise incipient tuberculosis disease, but not to protect against tuberculosis disease resulting from reinfection after completion of the treatment course. Although it is not possible to distinguish between reactivation and reinfection tuberculosis cases in this study, we suggest that the limited time available for reinfection and subsequent progression to disease after completing 3HP makes the latter possibility less likely.
The study was subject to a number of limitations. The hybrid design required an open-label treatment group,2 with no placebo for RISK11-positive participants, so that risk for tuberculosis could also be evaluated in the control group while concealing RISK11 status from participants, site staff, and tuberculosis endpoint laboratory staff for analysis of biomarker performance. Tuberculosis case accrual during the latter stages of follow-up suggested no evidence of ascertainment bias during treatment. Extensive study simulations were done to inform the size of each group for the coprimary analyses. However, due to lower than expected prevalence of RISK11-positive status in the screened population (9·3% vs 15%), enrolment of 1139 RISK11-positive individuals required 2 years, compared with planned enrolment of 1500 RISK11-positive individuals over 1 year. As a result, fewer than expected incident tuberculosis outcomes were observed (24 vs 40 primary endpoints), which might have reduced power for both treatment efficacy and RISK11 performance analyses. Not all participants in the treatment group completed 3HP per protocol, because study drug was discontinued for suspected hypersensitivity reactions or influenza-like illnesses. However, the discontinuation rate (7·5%) was comparable to other trials of 3HP, in which study drug was discontinued in 17·9% of participants overall and in 4·9% due to an adverse event.21 The loss to follow-up rate in this trial (14·4%) was higher than expected and might reflect the challenges of retaining the study participants, in the absence of traditional tuberculosis risk factors for which surveillance is routine. However, loss to follow-up occurred predominantly after the treatment period and did not seem to have been biased by treatment factors. We note that median duration of participation was 13·9 months and thus loss to follow-up did not have major unforeseen effect on statistical power. Strengths of the study include enrolment in geographically distinct sites across South Africa that were representative of populations with different rates of IFNγ release assay positivity and tuberculosis disease, which were congruent with local rates of RISK11 positivity, although the sample size was not sufficient for analysis of signature performance or 3HP efficacy at site level. The findings broadly reflect the South African tuberculosis epidemic, but might not be directly applicable to countries with much lower tuberculosis incidence.
It is not yet known whether other parsimonious tuberculosis signatures, developed and validated like RISK11 in carefully curated case-control studies, will exhibit similar performance characteristics when prospectively tested in the field, where undiagnosed subclinical tuberculosis might pose a challenge to diagnostic performance. Head-to-head analyses of several transcriptomic tuberculosis signatures with promising diagnostic performance are currently underway on CORTIS samples and novel near-patient testing platforms are in development, which might bring cost-effective, community-based tuberculosis biomarker screening closer to implementation in the field. However, although we have shown that a strategy of biomarker-guided tuberculosis preventive therapy is feasible, the optimal preventive therapy regimen for use in such a strategy remains elusive.
Data sharing
Deidentified RISK11 signature scores and primary tuberculosis endpoint data from all participants will be available with publication. The dataset is deposited in Zivahub (https://doi.org/10.25375/uct.13573337.v1), an open access data repository hosted by the University of Cape Town's institutional data repository powered by Figshare for Institutions.
Supplementary Material
Supplementary appendix
Acknowledgments
The trial was funded by the Bill & Melinda Gates Foundation (OPP1116632, OPP1137034) and the Strategic Health Innovation Partnerships Unit of the South African Medical Research Council with funds received from the South African Department of Science and Technology. Rifapentine was donated by the manufacturer (Sanofi). The authors thank the members of the data and safety monitoring board and the trial steering committee.
Contributors
TJS, AF-G, AP-N, SS, GW, KN, GC, and MH designed the study. CI, WB, AH, STM, RH-M, MT, GW, KN, and GC recruited and evaluated participants. TJS, AP-N, SKM, SCM, KH, MM, NB, ME, LJ, and RR collected and analysed laboratory data. AF-G, and BB accessed and verified the data. TJS, AF-G, AP-N, HM, BB, TS, RGW, and MH analysed data and interpreted results. KH, CH, and MK provided operational support. TJS, AF-G, HM, and MH drafted the Article. All authors had full access to the data, and reviewed, revised and gave final approval of the Article before submission.
The CORTIS-01 Study Team
Kesenogile Baepanye, Tshepiso Baepanye, Ken Clarke, Marelize Collignon, Audrey Dlamini, Candice Eyre, Tebogo Feni, Moogo Fikizolo, Phinda Galane, Thelma Goliath, Alia Gangat, Shirley Malefo-Grootboom, Elba Janse van Rensburg, Bonita Janse van Rensburg, Sophy Kekana, Marietjie Zietsman, Adrianne Kock, Israel Kunene, Aneessa Lakhi, Nondumiso Langa, Hilda Ledwaba, Marillyn Luphoko, Immaculate Mabasa, Dorah Mabe, Nkosinathi Mabuza, Molly Majola, Mantai Makhetha, Mpho Makoanyane, Blossom Makhubalo, Vernon Malay, Juanita Market, Selvy Matshego, Nontsikelelo Mbipa, Tsiamo Mmotsa, Sylvester Modipa, Samuel Mopati, Palesa Moswegu, Primrose Mothaga, Dorothy Muller, Grace Nchwe, Maryna Nel, Lindiwe Nhlangulela, Bantubonke Ntamo, Lawerence Ntoahae, Tedrius Ntshauba, Nomsa Sanyaka, Letlhogonolo Seabela, Pearl Selepe, Melissa Senne, MG Serake, Maria Thlapi, Vincent Tshikovhi, Lebogang Tswaile, Amanda van Aswegen, Lungile Mbata, Constance Takavamanya, Pedro Pinho, John Mdlulu, Marthinette Taljaard, Naydene Slabbert, Sharfuddin Sayed, Tanya Nielson, Melissa Senne, Ni Ni Sein, Lungile Mbata (The Aurum Institute); Dhineshree Govender, Tilagavathy Chinappa, Mbali Ignatia Zulu, Nonhle Bridgette Maphanga, Senzo Ralph Hlathi, Goodness Khanyisile Gumede, Thandiwe Yvonne Shezi, Jabulisiwe Lethabo Maphanga, Zandile Patrica Jali, Thobelani Cwele, Nonhlanhla Zanele Elsie Gwamanda, Celaphiwe Dlamini, Zibuyile Phindile Penlee Sing, Ntombozuko Gloria Ntanjana, Sphelele Simo Nzimande, Siyabonga Mbatha, Bhavna Maharaj, Atika Moosa, Cara-Mia Corris (Centre for the AIDS Programme of Research in South Africa); Fazlin Kafaar, Marwou De Kock, Hennie Geldenhuys, Angelique Kany Kany Luabeya, Justin Shenje, Natasja Botes, Susan Rossouw, Hadn Africa, Bongani Diamond, Samentra Braaf, Sonia Stryers, Alida Carstens, Ruwiyda Jansen, Simbarashe Mabwe, Roxane Herling, Ashley Veldsman, Lebohgang Makhete, Marcia Steyn, Sivuyile Buhlungu, Margareth Erasmus, Ilse Davids, Patiswa Plaatjie, Alessandro Companie, Frances Ratangee, Helen Veldtsman, Christel Petersen, Charmaine Abrahams, Miriam Moses, Xoliswa Kelepu, Yolande Gregg, Liticia Swanepoel, Nomsitho Magawu, Nompumelelo Cetywayo, Lauren Mactavie, Habibullah Valley, Elizabeth Filander, Nambitha Nqakala, Angelique Mouton, Fajwa Opperman, Elma Van Rooyen, Petrus Tyambetyu (South African Tuberculosis Vaccine Initiative, University of Cape Town); Elizna Maasdorp, Justine Khoury, Belinda Kriel, Bronwyn Smith, Liesel Muller, Susanne Tonsing, Andre Loxton, Andriette Hiemstra, Petri Ahlers, Marika Flinn (DST/NRF Centre of Excellence for Biomedical TB Research and SAMRC Centre for TB Research, Stellenbosch University); and Eva Chung, Michelle Chung, Alicia Sato (Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Research Center)
Declaration of interests
TJS has a patent of the RISK11 signature pending and reports grants from the Bill and Melinda Gates Foundation and South African Medical Research Council. KN reports grants from CAPRISA. GW reports a patent (PCT/IB2019/052043) pending to University of Cape Town, Stellenbosch University, Max-Planck-Gesellschaft Zur Foerderung Der Wissenschaften EV, Seattle Children's Hospital Doing Business as Seattle Children's Research Institute, and UK Research and Innovation. GC reports grants from the Bill & Melinda Gates Foundation. AP-N has a patent of the RISK11 signature pending and reports grants from the Bill & Melinda Gates Foundation and the South African Medical Research Council. MH reports grants from the Bill & Melinda Gates Foundation and the South African Medical Research Council. | UNK UNK, ONCE WEEKLY | DrugDosageText | CC BY | 33508224 | 20,168,180 | 2021-03 |
Give an alphabetized list of all active substances of drugs taken by the patient who experienced 'Therapeutic product effect incomplete'. | Resolution of Persistent Auditory Verbal Hallucinations after Long-term Electroconvulsive Therapy Maintenance: A Case Report of a Patient with Clozapine-resistant Schizophrenia.
A 32-year-old woman with schizophrenia and persistent auditory verbal hallucinations (AVHs), which caused continuous suicidal thoughts and depression, was treated with electroconvulsive therapy (ECT) of an acute course followed by maintenance ECT (M-ECT) augmented onto clozapine for 7 years. Although the general psychopathology and AVHs initially reduced slightly with ECT and clozapine, her AVHs and suicidal thoughts did not decrease subjectively. When 3 years of M-ECT, her voices declined sharply, and improvement was maintained for 2 years thereafter. A total 91 ECT sessions were performed. The daily clozapine dose was decreased from 325 to 200 mg and plasma levels remained higher than 350 ng/ml; there were no noticeable cognitive side effects. In summary, we report a case showing a sudden sharp reduction in persistent AVHs after 3 years of long-term M-ECT.
INTRODUCTION
Auditory verbal hallucinations (AVHs) are the most common symptom of schizophrenia, occurring in 60−80% of patients [1
-3]. Although clozapine is highly effective in reducing AVHs and can be used on a long-term basis, more than 25% of patients treated with clozapine continue to suffer from AVHs [2,4
-7]. Persistent AVHs are associated with an increased risk of suicide, violence, and hospitalization [8
-10].
Electroconvulsive therapy (ECT) augmentation onto clozapine has been reported to be particularly effective for refractory schizophrenia [11
-14]. However, the ECT effect on hallucinations per se has never been demonstrated, rendering its efficacy low [7,15,16]. Nonetheless, there is no evidence that the therapeutic effect of ECT diminishes over time; rather, it appears to get stronger with continuing treatment [17,18]. Additionally, there is no evidence of persistent cognitive side effects associated with maintenance ECT (M-ECT) [14,19,20], and several studies have actually shown improved cognition over time [13]. Well-designed studies of the long-term M-ECT effects on persistent AVHs in patients with schizophrenia in terms of symptom resolution, persistence of any improvement, and relapse prevention are very limited [13,17,21]. Therefore, even case reports of very long-term ECT treatment could contribute to our understanding of the M-ECT effects on persistent AVHs [17].
We present the case of a female patient with schizophrenia who suffered from persistent AVHs associated with suicidal thoughts and depression despite long-term clozapine treatment. During 7 years of ECT and clozapine, persistent AVHs were eventually resolved and stabilized without significant cognitive side effects. This case report has been exempted from review by the Institutional Review Board, and written consent was provided by the patient.
CASE
A 32-year-old unmarried woman, diagnosed with schizophrenia according to the Diagnostic and Statistical Manual of Mental Disorder-fourth and fifth editions (DSM-IV and V, respectively), reported persistent AVHs characterized by multiple voices and sexual content since her junior year of university at the age of 20 years. AVHs were heard almost all day and centered on accusations or intimidation by voices of men, women and even groups; these symptoms had interfered with her social activities for many years and led to several suicide attempts. She was hospitalized for recurrent psychotic symptoms, including severe AVHs, and started clozapine since 2008 after the failure of various antipsychotic medicines. In 2013, she transferred to our hospital with persistent AVHs and suicidal thoughts; her medications were clozapine 300 mg, aripiprazole 2 mg, escitalopram 10 mg, and clonazepam 0.5 mg. We attempted to increase the daily clozapine dose by more than 400 mg, but this failed because the plasma clozapine concentrations fluctuated and were frequently higher than 1,000 ng/ml.
Augmentation of the clozapine treatment with ECT was recommended. After approval by the hospital’s ECT Task Committee, acute course of ECT was performed 16 sessions in 46 days at the end of 2013. The electrical stimulus was delivered with a 1.0-ms brief pulse width and bilateral electrode placement by the upward titration method using a Spectrum 5000Q instrument (MECTA Corporation, Portland, OR, USA). Although she continued to experience AVHs after the acute ECT, she was relatively tolerant of clozapine 325 mg, diazepam 10 mg, and trihexyphenidyl 4 mg, and no further ECT was performed.
Eight months later in August 2014, she complained of escalating AVHs associated with increased irritability, depression, and suicidal thoughts. ECT was recommended again at irregular intervals, i.e., once every 1−3 weeks because her overall psychopathology was not as severe as when ECT was initiated. Although her voices were not reduced to be able to continue her daily life, she became tolerable and went on receiving treatment. In the fall of 2017, her voices suddenly diminished, and she was able to recommence with social activities, including a close interpersonal relationship, shopping trips with her mother, and so on. Her medications were clozapine 200 mg, aripiprazole 2 mg, divalproex sodium 250 mg, and lorazepam 1 mg that were maintained for almost 2 years thereafter. Additionally, the inter-treatment intervals became to increase gradually to up to 6 weeks. The patient received 91 ECT sessions up to May of 2019, at energy levels of 80−384 mC; she has maintained 120 mC of electricity since September 2017.
Total scores of Positive and Negative Syndrome Scale (PANSS), Hamilton Program for Schizophrenia Voices Questionnaire (HPSVQ) (Fig. 1) and Scale for Suicide Ideation (SSI) before starting ECT were 95 (positive syndrome: 22, negative syndrome: 24, general psychopathology: 49), 34 (emotional factor: 16, physical factor: 18) and 18, respectively. These scores at the end of acute ECT were 80 (21, 18, and 41), 31 (15 and 16) and 9, respectively. In the fall of 2017, when the patient experienced a sudden reduction in AVHs, the scores were 76 (15, 26, and 35), 17 (4 and 13) and 3, respectively. Scores at the last observation, in May 2019, were 65 (16, 20, and 29), 19 (4 and 15) and 4, respectively.
Although systematic neurocognitive tests were not performed regularly, we did administer the Korean version of the Mini-Mental State Examination (MMSE-KC) and the Korean Version of the Montreal Cognitive Assessment (MoCA-K) at approximately 2-month intervals (mean interval, 65.2 ± 58.4 days). The MMSE-KC scores never fell below 28 points during acute ECT, and most of the MMSE-KC and MoCA-K scores were in the range of 27−30 points during the M-ECT period; even when they temporarily dropped to 22−26 points, they returned to the normal range in a few days.
DISCUSSION
The present patient noticed a sudden remarkable decrease in persistent AVHs and suicidal thoughts when M-ECT and clozapine lasted for 3 years and was comfortable for the first time since her initial experience of AVHs. At the time she reported subjective improvement in AVHs, a clear decrease of 45.2% (from 31 to 17) in total HPSVQ score compared to when M-ECT was started, mainly due to the emotional factor, was noted in contrast to a 5.0% (from 80 to 76) decrease in the PANSS total score. Suicidal thoughts were also reduced by SSI. This improvement was subsequently maintained. Her daily clozapine dose was continued at 200 mg, but her clozapine plasma levels were never lower than 350 ng/ml during the observation period to rule out pseudo-resistance to clozapine. There were no noticeable cognitive side effects associated with M-ECT. It can be concluded that long-term ECT augmentation is effective for the resolution of the AVHs in this patient with insufficient response to clozapine [7,19].
More specifically, the sharp reduction in AVHs was caused primarily by the suddenly remarkable decrease in the emotional factor score, from 11−16 to 4 points. However, the monotonic decrease in total and emotional factor HPSVQ scores during M-ECT seemed not to be associated with PANSS scores, which gradually decreased during the observation period. This patient shows that long-term M-ECT may eventually lead to symptom reduction along with decreasing suicide thoughts even when the daily clozapine dose is gradually decreased to 200 mg. The sustained improvement with lower clozapine doses therein suggests that decreased doses did not affect the therapeutic effect of M-ECT [14,17,18].
One critical issue related to M-ECT concerns its potential to adversely affect cognitive function. However, it has been argued that evidence for worsening memory secondary to M-ECT is lacking [20]. Our previous study found that cognitive scale scores did not change over a 2-year observation period [14], and as mentioned above, a case report of 321 ECT sessions on a weekly base indicated no reduction in cognitive function [18]. It has been hypothesized that the reason that cognitive decline has not been observed in M-ECT relates to the increased inter-treatment intervals, which allow the brain sufficient time to recover [21,22]. Additionally, the use of bilateral electrode placement in single treatments separated by long intervals would not be expected to cause significant cognitive impairment [23]. Like previous researches [14], the present study did not detect any long-term decline in cognitive functioning during M-ECT, according to the MMSE-KC and MoCA-K.
In conclusion, this case demonstrates that AVHs may eventually improve, even in clozapine-resistant schizophrenia with persistent AHVs, when long-term M-ECT is continued. Further long-term follow-up studies including large numbers of patients may further elucidate the effectiveness of long-term M-ECT for persistent AVHs.
Conflicts of Interest
Dr. Kim YS received grants, research support and honoraria from Janssen, Otsuka, Hanmi, and Dainippon Sumitomo. Dr. Chung IW received research grants from Janssen, Otsuka, Hanmi, Whanin, Bukwang and educational grant from Mecta. Others have no conflicts of interest.
Author Contributions
Conceptualization: Yong Sik Kim. Data acquisition: Hye Sung Kim, Jung Hyun Kim, Jin Hyeok Jang. Formal analysis: In Won Chung, Yong Sik Kim. Funding: Yong Sik Kim. Supervision: Yong Sik Kim. Writing—original draft: In Won Chung, Yong Sik Kim. Writing—review & editing: In Won Chung, Yong Sik Kim.
Fig. 1 Changes in Hamilton Program for Schizophrenia Voices Questionnaire (HPSVQ) scores during combined electroconvulsive therapy (ECT) and clozapine treatment of a patient with treatment- resistant schizophrenia The vertical lines at the bottom of the graph indicate the dates of ECT. The Kendall’s tau (pvalue) for total, emotional factor, and physical factor HPSVQ scores was −0.310 (0.0242), −0.395 (0.0059), and −0.130 (0.404), respectively, when M-ECT data (after August of 2014) were analyzed. The total and positive syndrome, negative syndrome, and general psychopathology scores on the PANSS were −0.0883 (p = 0.584), −0.317 (p = 0.0510), 0.381 (p = 0.0190), and −0.128 (p = 0.428), respectively. The pvalue indicates the significance value whether Kendall’s tau was zero or not. M-ECT, maintenance ECT; PANSS, Positive and Negative Syndrome Scale. | CLOZAPINE | DrugsGivenReaction | CC BY-NC | 33508802 | 19,069,497 | 2021-02-28 |
Give an alphabetized list of all active substances of drugs taken by the patient who experienced 'Therapeutic product effect incomplete'. | Cariprazine Add-on in Inadequate Clozapine Response: A Report on Two Cases.
Cariprazine is a novel antipsychotic drug that exerts partial agonism of dopamine D2/D3 receptors with preferential binding to the D3 receptor, antagonism of 5HT2B receptors, and partial agonism of 5HT1A. Currently, cariprazine has shown clinical efficacy in patients with schizophrenia and with bipolar disorder, as well as adjunctive treatment in patients with Major Depressive Disorder (MDD) and drug-resistant MDD. In the present case series, we report on two patients with treatment-resistant schizophrenia and partial response to clozapine who benefit from combination with cariprazine. The effects of cariprazine combination were remarkable also concerning the adverse metabolic effects of clozapine.
INTRODUCTION
Schizophrenia is a chronic and devastating disease affecting around 0.5% of the population [1]. It is known that the complete remission or recovery of symptoms is relatively rare in schizophrenia, and the treatment resistance remains one of the most critical challenges in psychiatry [2]. The gold standard in the case of resistant schizophrenia is the clozapine treatment [3]. However, despite the greater efficacy of clozapine over other antipsychotics in the management of resistant schizophrenia, a signifi-cant number of patients fail to attain adequate response or develop clozapine-related adverse effects, and clozapine-resistant schizophrenia represents a challenge for the clinician and a calamity for the patients [4,5].
Cariprazine, also named the “rip” [6], is a novel second-generation antipsychotic with antagonist-partial agonist properties at D2 and D3 receptors, with preferential binding to the D3 receptors [7]. Cariprazine has been approved by the Food and Drug Administration for the treatment of adult patients with schizophrenia (Europe and USA) and acute treatment of manic/ and mixed episodes of bipolar disorder (only USA) [8,9].
Cariprazine acts as an antagonist or partial agonist at D2/D3 receptors, depending on the endogenous dopaminergic tone [10]. At high dopamine levels, it seems to act as an antagonist, while at lower dopamine levels, it exerts its agonist action, by increasing the dopamine receptor activity [11,12]. It preferentially has a 5- to 30-fold greater affinity for human D3 receptors (Ki = 0.085 nM) than for the D2L (Ki = 0.49 nM) and D2S (Ki = 0.69 nM) [13]. Meanwhile, even though to a more limited extent, cariprazine also shows partial agonism at the 5HT1A receptors (Ki = 2.46 nM), hence by exerting an antidepressant effect in addition to the antipsychotic effect [14,15]. Moreover, cariprazine also shows an antagonist at human 5HT2B receptors (Ki = 0.58 nM), which has a crucial role in modulating dopamine release in the nucleus accumbens [16].
Interestingly, besides the positive effects on positive symptoms, cariprazine is associated with improvements in primary negative symptoms of schizophrenia and these improvements are unlikely to result from improved positive or overall symptoms [17].
In the present paper, we report on two cases of treatment-resistant schizophrenia with inadequate response to clozapine who were successfully treated with cariprazine combination in the outpatient facility of Hospital of Teramo, Italy.
CASE
Case 1
She is a 29-year-old unemployed and unmarried woman with a long history of schizophrenia diagnosed when she was 19-year-old with an acute episode characterized by mixed positive and negative symptoms with marked hostility. During the years, she underwent several treatments with both oral (haloperidol, olanzapine, and paliperidone) and long-acting antipsychotics (haloperidol decanoate and aripiprazole long-acting) with no effects on psychopathology. Then, from almost one year, she was switched to clozapine 450 mg/day with an inadequate response, despite a tentative to augment with amisulpride 800 mg/die that was reported ineffective. In fact, at the time of our observation (referred to us by her general practitioner) the patient was symptomatic, and the scores of Positive and Negative Symptoms Scale (PANSS) were still clinically significant (total score = 113, positive = 22, negative = 33, general = 58). Moreover, the patient developed weight gain during clozapine treatment (at the time of our first observation, her body weight was 84 kg, and body mass index [BMI] was 26.8 kg/m2).
Thus, considering the failure of previous treatment with aripiprazole (due to a non response, but without adverse effects), cariprazine combination was offered and introduced at the initial dosage of 1.5 mg in the morning. After a week, cariprazine was titrated to 3 mg/die without adverse effects. After 30 days of cariprazine combination we observed an improvement in PANSS scores (total score = 89, positive = 18, negative = 27, general = 44). After other three months of therapy, the PANSS scores were remarkably improved (total score = 74, positive = 14, negative = 20, general = 40) without adverse effects reported. Moreover, we noted a significant improvement in weight (79 kg) and BMI (25.1 kg/m2).
The last observation was carried out in September 2019, after other four months of combination therapy, and the PANSS scores further improved (total score = 57, positive = 10, negative = 14, general = 33) as well as the BMI (24.6 kg/m2). The patient found a job as a part-time working in handbag manufacture with a reported good yield and performed a regular and moderate physical activity three times a week. No adverse effects were reported or observed, and the patient was taking 400 mg/day of clozapine and cariprazine 3 mg/day.
The subject gave us written informed consent for publication of this case report.
Case 2
He is a 35-year-old blue-collar unmarried man who was diagnosed with schizophrenia at the age of 24-year- old. His onset was accompanied by substance abuse (mainly cocaine and cannabis) and was characterized by positive symptoms, a marked impulse dyscontrol with great hostility and negative symptoms such as blunted affect, social withdrawal, and poor rapport. He was treated in the past with several antipsychotics (haloperidol, olanzapine, and paliperidone long-acting) without response and considerable problem in functioning (the patient lost his job). From almost one year and a half, he was taking clozapine 350 mg/day with a functional improvement only on hostility and uncooperativeness, without significant effects on other symptoms. He was also administered in the past clozapine 400 mg/day, but he developed marked sedation, and the dosage was reduced to 350 mg/day that was well tolerated. He willingly decided to consult us, and at the time of our observation, he was symptomatic, and the scores of PANSS were still clinically significant (total score = 121, positive = 27, negative = 34, general = 70).
Moreover, the patient was overweight even if he was unable to relate this to clozapine treatment (his body weight was 95 kg, and BMI was 28.4 kg/m2). He was offered to introduce aripiprazole, but he refused due to his friend, who was taking it and told him about unknown “adverse effects.” Then, cariprazine was offered, and he agreed to introduce it at an initial dosage of 1.5 mg/day. After three weeks of therapy, a slight improvement on PANSS was seen (total score = 101, positive = 20, negative = 30, general = 61), and the patient reported that he “felt better” especially on functioning and cognitions without adverse effects. The patient agreed to titrate cariprazine up to 3 mg/day. After other two months we observed an improvement of both PANSS (total score = 77, positive = 13, negative = 15, general = 49) and BMI (26.9 kg/m2), and clozapine was reduced to 300 mg/day. The improvement was constant, and he was able to find a job as blue collar in a brick factory as “…my mind and thoughts are more clear…”.
The last observation was conducted in September 2019 after further three months of combination therapy, and the PANSS scores were also improved (total score = 57, positive = 9, negative = 12, general = 29) as well as the BMI (25.6 kg/m2). No adverse effects were reported or observed, and the patient was taking 300 mg/day of clozapine and cariprazine 3 mg/day.
The subject gave us written informed consent for publication of this case report.
DISCUSSION
To date, these were the first cases of cariprazine combination with clozapine in the occurrence of inadequate response to the latter. Cariprazine combination showed a remarkable effect, as demonstrated by a reduction in PANSS scores over time.
Even if the decrease in PANSS scores was observed for all subscales, a noticeable reduction was obtained concerning negative symptoms that are in line with the mechanism of action on D3 of cariprazine [18]. The D3 receptors, structurally similar to the D2 receptor, are auto-receptors able to modulate the phasic dopaminergic activity and linked to cognition, mood, emotions and reward/substance abuse [19]. Therefore, some authors support its potential role as a pro-cognitive agent and effective treatment in the management of negative symptoms of schizophrenia and an enhancer of the working memory as well [20]. Several studies have suggested that cariprazine affinity and action on D3 may explain its efficacy on negative symptoms, executive deficits, cognitive and mood impairment [21,22]. D3 receptors are identified at the asymmetric synapses at the head of dendritic spines, a localization that is in sharp contrast with D1 and D2 receptors, which are both pre-synaptic or spread all over dendrites and dendritic spines in neurons of the caudate putamen and NAc [20,23,24]. Moreover, the high concentration of the D3 receptors in the ventral striatum, as compared to the dorsal part, increases the probability that D3 antagonists may have an antipsychotic action with negligible adverse effects including extrapyramidal side effects and catalepsy [25
-27].
Moreover, even though to a more limited extent, cariprazine also shows partial agonism at the 5HT1A receptors, hence by exerting an antidepressant effect in addition to the antipsychotic effect [28]. These mechanisms may explain the positive impact of the cariprazine-clozapine combination seen in these cases.
It is also possible to hypothesize a pharmacokinetic interaction between cariprazine and clozapine to explain the positive outcome of this combination. Cariprazine primarily undergoes dealkylation, dydroxylation, N-oxidation, and cleavage by CYP3A4 and, to a small degree, by CYP2D6 in hepatic microsomes [29]. Clozapine is mostly metabolized in the liver by the CYP1A2 and CYP1A2 activity is an essential determinant of clozapine dose [30]. Other liver enzymes involved in clozapine metabolism include CYP2D6 and CYP3A4 [31]. As the involvement of CYP3A4 in clozapine metabolism is secondary [32], one may hypothesize that a drug-drug interaction with cariprazine may be unlikely. Unluckily we did not evaluate clozapine blood levels, but none of patients reported symptoms of excessive clozapine dosage. Both patients were administered the maximum tolerated doses of clozapine, and no adverse events were reported.
Besides, we observed a good effect on weight and BMI with a reduction of both parameters with cariprazine combination. This effect may be explained by both cariprazine pro-cognitive action (both of patients started to perform a moderate physical activity) and by the decrease in negative symptoms through the action on D3 receptors [22]. Moreover, cariprazine binds to the 5HT2A (Ki = 19 nM) that may be involved in pro-cognitive activity [33] while it has a lower affinity for 5HT7 (Ki = 111 nM), 5HT2C (Ki = 134 nM) and a1 receptors, by exerting an antagonist action. Its weak action on these receptors may further explain its good metabolic profile [34]. Concerning cariprazine adverse effects [12,35], post hoc analyses of safety data from cariprazine studies in schizophrenia showed a dose-response association for several treatment-emergent adverse events and clinical laboratory values including akathisia, extrapyramidal symptoms, creatine phosphokinase and transaminase elevations, increases in blood pressure, but none of these were observed in our cases.
In conclusion, cariprazine add-on to clozapine showed remarkable and relatively rapid efficacy in the treatment of subjects with inadequate response to clozapine. The tolerability of this association was excellent without reported adverse effects. However, future studies on larger samples are needed to elucidate this positive effect better.
Conflicts of Interest
No potential conflict of interest relevant to this article was reported.
Author Contributions
All the Authors contributed to this case series with equal efforts. | CARIPRAZINE, CLOZAPINE | DrugsGivenReaction | CC BY-NC | 33508803 | 19,070,008 | 2021-02-28 |
Give an alphabetized list of all active substances of drugs taken by the patient who experienced 'Weight increased'. | Cariprazine Add-on in Inadequate Clozapine Response: A Report on Two Cases.
Cariprazine is a novel antipsychotic drug that exerts partial agonism of dopamine D2/D3 receptors with preferential binding to the D3 receptor, antagonism of 5HT2B receptors, and partial agonism of 5HT1A. Currently, cariprazine has shown clinical efficacy in patients with schizophrenia and with bipolar disorder, as well as adjunctive treatment in patients with Major Depressive Disorder (MDD) and drug-resistant MDD. In the present case series, we report on two patients with treatment-resistant schizophrenia and partial response to clozapine who benefit from combination with cariprazine. The effects of cariprazine combination were remarkable also concerning the adverse metabolic effects of clozapine.
INTRODUCTION
Schizophrenia is a chronic and devastating disease affecting around 0.5% of the population [1]. It is known that the complete remission or recovery of symptoms is relatively rare in schizophrenia, and the treatment resistance remains one of the most critical challenges in psychiatry [2]. The gold standard in the case of resistant schizophrenia is the clozapine treatment [3]. However, despite the greater efficacy of clozapine over other antipsychotics in the management of resistant schizophrenia, a signifi-cant number of patients fail to attain adequate response or develop clozapine-related adverse effects, and clozapine-resistant schizophrenia represents a challenge for the clinician and a calamity for the patients [4,5].
Cariprazine, also named the “rip” [6], is a novel second-generation antipsychotic with antagonist-partial agonist properties at D2 and D3 receptors, with preferential binding to the D3 receptors [7]. Cariprazine has been approved by the Food and Drug Administration for the treatment of adult patients with schizophrenia (Europe and USA) and acute treatment of manic/ and mixed episodes of bipolar disorder (only USA) [8,9].
Cariprazine acts as an antagonist or partial agonist at D2/D3 receptors, depending on the endogenous dopaminergic tone [10]. At high dopamine levels, it seems to act as an antagonist, while at lower dopamine levels, it exerts its agonist action, by increasing the dopamine receptor activity [11,12]. It preferentially has a 5- to 30-fold greater affinity for human D3 receptors (Ki = 0.085 nM) than for the D2L (Ki = 0.49 nM) and D2S (Ki = 0.69 nM) [13]. Meanwhile, even though to a more limited extent, cariprazine also shows partial agonism at the 5HT1A receptors (Ki = 2.46 nM), hence by exerting an antidepressant effect in addition to the antipsychotic effect [14,15]. Moreover, cariprazine also shows an antagonist at human 5HT2B receptors (Ki = 0.58 nM), which has a crucial role in modulating dopamine release in the nucleus accumbens [16].
Interestingly, besides the positive effects on positive symptoms, cariprazine is associated with improvements in primary negative symptoms of schizophrenia and these improvements are unlikely to result from improved positive or overall symptoms [17].
In the present paper, we report on two cases of treatment-resistant schizophrenia with inadequate response to clozapine who were successfully treated with cariprazine combination in the outpatient facility of Hospital of Teramo, Italy.
CASE
Case 1
She is a 29-year-old unemployed and unmarried woman with a long history of schizophrenia diagnosed when she was 19-year-old with an acute episode characterized by mixed positive and negative symptoms with marked hostility. During the years, she underwent several treatments with both oral (haloperidol, olanzapine, and paliperidone) and long-acting antipsychotics (haloperidol decanoate and aripiprazole long-acting) with no effects on psychopathology. Then, from almost one year, she was switched to clozapine 450 mg/day with an inadequate response, despite a tentative to augment with amisulpride 800 mg/die that was reported ineffective. In fact, at the time of our observation (referred to us by her general practitioner) the patient was symptomatic, and the scores of Positive and Negative Symptoms Scale (PANSS) were still clinically significant (total score = 113, positive = 22, negative = 33, general = 58). Moreover, the patient developed weight gain during clozapine treatment (at the time of our first observation, her body weight was 84 kg, and body mass index [BMI] was 26.8 kg/m2).
Thus, considering the failure of previous treatment with aripiprazole (due to a non response, but without adverse effects), cariprazine combination was offered and introduced at the initial dosage of 1.5 mg in the morning. After a week, cariprazine was titrated to 3 mg/die without adverse effects. After 30 days of cariprazine combination we observed an improvement in PANSS scores (total score = 89, positive = 18, negative = 27, general = 44). After other three months of therapy, the PANSS scores were remarkably improved (total score = 74, positive = 14, negative = 20, general = 40) without adverse effects reported. Moreover, we noted a significant improvement in weight (79 kg) and BMI (25.1 kg/m2).
The last observation was carried out in September 2019, after other four months of combination therapy, and the PANSS scores further improved (total score = 57, positive = 10, negative = 14, general = 33) as well as the BMI (24.6 kg/m2). The patient found a job as a part-time working in handbag manufacture with a reported good yield and performed a regular and moderate physical activity three times a week. No adverse effects were reported or observed, and the patient was taking 400 mg/day of clozapine and cariprazine 3 mg/day.
The subject gave us written informed consent for publication of this case report.
Case 2
He is a 35-year-old blue-collar unmarried man who was diagnosed with schizophrenia at the age of 24-year- old. His onset was accompanied by substance abuse (mainly cocaine and cannabis) and was characterized by positive symptoms, a marked impulse dyscontrol with great hostility and negative symptoms such as blunted affect, social withdrawal, and poor rapport. He was treated in the past with several antipsychotics (haloperidol, olanzapine, and paliperidone long-acting) without response and considerable problem in functioning (the patient lost his job). From almost one year and a half, he was taking clozapine 350 mg/day with a functional improvement only on hostility and uncooperativeness, without significant effects on other symptoms. He was also administered in the past clozapine 400 mg/day, but he developed marked sedation, and the dosage was reduced to 350 mg/day that was well tolerated. He willingly decided to consult us, and at the time of our observation, he was symptomatic, and the scores of PANSS were still clinically significant (total score = 121, positive = 27, negative = 34, general = 70).
Moreover, the patient was overweight even if he was unable to relate this to clozapine treatment (his body weight was 95 kg, and BMI was 28.4 kg/m2). He was offered to introduce aripiprazole, but he refused due to his friend, who was taking it and told him about unknown “adverse effects.” Then, cariprazine was offered, and he agreed to introduce it at an initial dosage of 1.5 mg/day. After three weeks of therapy, a slight improvement on PANSS was seen (total score = 101, positive = 20, negative = 30, general = 61), and the patient reported that he “felt better” especially on functioning and cognitions without adverse effects. The patient agreed to titrate cariprazine up to 3 mg/day. After other two months we observed an improvement of both PANSS (total score = 77, positive = 13, negative = 15, general = 49) and BMI (26.9 kg/m2), and clozapine was reduced to 300 mg/day. The improvement was constant, and he was able to find a job as blue collar in a brick factory as “…my mind and thoughts are more clear…”.
The last observation was conducted in September 2019 after further three months of combination therapy, and the PANSS scores were also improved (total score = 57, positive = 9, negative = 12, general = 29) as well as the BMI (25.6 kg/m2). No adverse effects were reported or observed, and the patient was taking 300 mg/day of clozapine and cariprazine 3 mg/day.
The subject gave us written informed consent for publication of this case report.
DISCUSSION
To date, these were the first cases of cariprazine combination with clozapine in the occurrence of inadequate response to the latter. Cariprazine combination showed a remarkable effect, as demonstrated by a reduction in PANSS scores over time.
Even if the decrease in PANSS scores was observed for all subscales, a noticeable reduction was obtained concerning negative symptoms that are in line with the mechanism of action on D3 of cariprazine [18]. The D3 receptors, structurally similar to the D2 receptor, are auto-receptors able to modulate the phasic dopaminergic activity and linked to cognition, mood, emotions and reward/substance abuse [19]. Therefore, some authors support its potential role as a pro-cognitive agent and effective treatment in the management of negative symptoms of schizophrenia and an enhancer of the working memory as well [20]. Several studies have suggested that cariprazine affinity and action on D3 may explain its efficacy on negative symptoms, executive deficits, cognitive and mood impairment [21,22]. D3 receptors are identified at the asymmetric synapses at the head of dendritic spines, a localization that is in sharp contrast with D1 and D2 receptors, which are both pre-synaptic or spread all over dendrites and dendritic spines in neurons of the caudate putamen and NAc [20,23,24]. Moreover, the high concentration of the D3 receptors in the ventral striatum, as compared to the dorsal part, increases the probability that D3 antagonists may have an antipsychotic action with negligible adverse effects including extrapyramidal side effects and catalepsy [25
-27].
Moreover, even though to a more limited extent, cariprazine also shows partial agonism at the 5HT1A receptors, hence by exerting an antidepressant effect in addition to the antipsychotic effect [28]. These mechanisms may explain the positive impact of the cariprazine-clozapine combination seen in these cases.
It is also possible to hypothesize a pharmacokinetic interaction between cariprazine and clozapine to explain the positive outcome of this combination. Cariprazine primarily undergoes dealkylation, dydroxylation, N-oxidation, and cleavage by CYP3A4 and, to a small degree, by CYP2D6 in hepatic microsomes [29]. Clozapine is mostly metabolized in the liver by the CYP1A2 and CYP1A2 activity is an essential determinant of clozapine dose [30]. Other liver enzymes involved in clozapine metabolism include CYP2D6 and CYP3A4 [31]. As the involvement of CYP3A4 in clozapine metabolism is secondary [32], one may hypothesize that a drug-drug interaction with cariprazine may be unlikely. Unluckily we did not evaluate clozapine blood levels, but none of patients reported symptoms of excessive clozapine dosage. Both patients were administered the maximum tolerated doses of clozapine, and no adverse events were reported.
Besides, we observed a good effect on weight and BMI with a reduction of both parameters with cariprazine combination. This effect may be explained by both cariprazine pro-cognitive action (both of patients started to perform a moderate physical activity) and by the decrease in negative symptoms through the action on D3 receptors [22]. Moreover, cariprazine binds to the 5HT2A (Ki = 19 nM) that may be involved in pro-cognitive activity [33] while it has a lower affinity for 5HT7 (Ki = 111 nM), 5HT2C (Ki = 134 nM) and a1 receptors, by exerting an antagonist action. Its weak action on these receptors may further explain its good metabolic profile [34]. Concerning cariprazine adverse effects [12,35], post hoc analyses of safety data from cariprazine studies in schizophrenia showed a dose-response association for several treatment-emergent adverse events and clinical laboratory values including akathisia, extrapyramidal symptoms, creatine phosphokinase and transaminase elevations, increases in blood pressure, but none of these were observed in our cases.
In conclusion, cariprazine add-on to clozapine showed remarkable and relatively rapid efficacy in the treatment of subjects with inadequate response to clozapine. The tolerability of this association was excellent without reported adverse effects. However, future studies on larger samples are needed to elucidate this positive effect better.
Conflicts of Interest
No potential conflict of interest relevant to this article was reported.
Author Contributions
All the Authors contributed to this case series with equal efforts. | CARIPRAZINE, CLOZAPINE | DrugsGivenReaction | CC BY-NC | 33508803 | 19,070,035 | 2021-02-28 |
What is the weight of the patient? | Cariprazine Add-on in Inadequate Clozapine Response: A Report on Two Cases.
Cariprazine is a novel antipsychotic drug that exerts partial agonism of dopamine D2/D3 receptors with preferential binding to the D3 receptor, antagonism of 5HT2B receptors, and partial agonism of 5HT1A. Currently, cariprazine has shown clinical efficacy in patients with schizophrenia and with bipolar disorder, as well as adjunctive treatment in patients with Major Depressive Disorder (MDD) and drug-resistant MDD. In the present case series, we report on two patients with treatment-resistant schizophrenia and partial response to clozapine who benefit from combination with cariprazine. The effects of cariprazine combination were remarkable also concerning the adverse metabolic effects of clozapine.
INTRODUCTION
Schizophrenia is a chronic and devastating disease affecting around 0.5% of the population [1]. It is known that the complete remission or recovery of symptoms is relatively rare in schizophrenia, and the treatment resistance remains one of the most critical challenges in psychiatry [2]. The gold standard in the case of resistant schizophrenia is the clozapine treatment [3]. However, despite the greater efficacy of clozapine over other antipsychotics in the management of resistant schizophrenia, a signifi-cant number of patients fail to attain adequate response or develop clozapine-related adverse effects, and clozapine-resistant schizophrenia represents a challenge for the clinician and a calamity for the patients [4,5].
Cariprazine, also named the “rip” [6], is a novel second-generation antipsychotic with antagonist-partial agonist properties at D2 and D3 receptors, with preferential binding to the D3 receptors [7]. Cariprazine has been approved by the Food and Drug Administration for the treatment of adult patients with schizophrenia (Europe and USA) and acute treatment of manic/ and mixed episodes of bipolar disorder (only USA) [8,9].
Cariprazine acts as an antagonist or partial agonist at D2/D3 receptors, depending on the endogenous dopaminergic tone [10]. At high dopamine levels, it seems to act as an antagonist, while at lower dopamine levels, it exerts its agonist action, by increasing the dopamine receptor activity [11,12]. It preferentially has a 5- to 30-fold greater affinity for human D3 receptors (Ki = 0.085 nM) than for the D2L (Ki = 0.49 nM) and D2S (Ki = 0.69 nM) [13]. Meanwhile, even though to a more limited extent, cariprazine also shows partial agonism at the 5HT1A receptors (Ki = 2.46 nM), hence by exerting an antidepressant effect in addition to the antipsychotic effect [14,15]. Moreover, cariprazine also shows an antagonist at human 5HT2B receptors (Ki = 0.58 nM), which has a crucial role in modulating dopamine release in the nucleus accumbens [16].
Interestingly, besides the positive effects on positive symptoms, cariprazine is associated with improvements in primary negative symptoms of schizophrenia and these improvements are unlikely to result from improved positive or overall symptoms [17].
In the present paper, we report on two cases of treatment-resistant schizophrenia with inadequate response to clozapine who were successfully treated with cariprazine combination in the outpatient facility of Hospital of Teramo, Italy.
CASE
Case 1
She is a 29-year-old unemployed and unmarried woman with a long history of schizophrenia diagnosed when she was 19-year-old with an acute episode characterized by mixed positive and negative symptoms with marked hostility. During the years, she underwent several treatments with both oral (haloperidol, olanzapine, and paliperidone) and long-acting antipsychotics (haloperidol decanoate and aripiprazole long-acting) with no effects on psychopathology. Then, from almost one year, she was switched to clozapine 450 mg/day with an inadequate response, despite a tentative to augment with amisulpride 800 mg/die that was reported ineffective. In fact, at the time of our observation (referred to us by her general practitioner) the patient was symptomatic, and the scores of Positive and Negative Symptoms Scale (PANSS) were still clinically significant (total score = 113, positive = 22, negative = 33, general = 58). Moreover, the patient developed weight gain during clozapine treatment (at the time of our first observation, her body weight was 84 kg, and body mass index [BMI] was 26.8 kg/m2).
Thus, considering the failure of previous treatment with aripiprazole (due to a non response, but without adverse effects), cariprazine combination was offered and introduced at the initial dosage of 1.5 mg in the morning. After a week, cariprazine was titrated to 3 mg/die without adverse effects. After 30 days of cariprazine combination we observed an improvement in PANSS scores (total score = 89, positive = 18, negative = 27, general = 44). After other three months of therapy, the PANSS scores were remarkably improved (total score = 74, positive = 14, negative = 20, general = 40) without adverse effects reported. Moreover, we noted a significant improvement in weight (79 kg) and BMI (25.1 kg/m2).
The last observation was carried out in September 2019, after other four months of combination therapy, and the PANSS scores further improved (total score = 57, positive = 10, negative = 14, general = 33) as well as the BMI (24.6 kg/m2). The patient found a job as a part-time working in handbag manufacture with a reported good yield and performed a regular and moderate physical activity three times a week. No adverse effects were reported or observed, and the patient was taking 400 mg/day of clozapine and cariprazine 3 mg/day.
The subject gave us written informed consent for publication of this case report.
Case 2
He is a 35-year-old blue-collar unmarried man who was diagnosed with schizophrenia at the age of 24-year- old. His onset was accompanied by substance abuse (mainly cocaine and cannabis) and was characterized by positive symptoms, a marked impulse dyscontrol with great hostility and negative symptoms such as blunted affect, social withdrawal, and poor rapport. He was treated in the past with several antipsychotics (haloperidol, olanzapine, and paliperidone long-acting) without response and considerable problem in functioning (the patient lost his job). From almost one year and a half, he was taking clozapine 350 mg/day with a functional improvement only on hostility and uncooperativeness, without significant effects on other symptoms. He was also administered in the past clozapine 400 mg/day, but he developed marked sedation, and the dosage was reduced to 350 mg/day that was well tolerated. He willingly decided to consult us, and at the time of our observation, he was symptomatic, and the scores of PANSS were still clinically significant (total score = 121, positive = 27, negative = 34, general = 70).
Moreover, the patient was overweight even if he was unable to relate this to clozapine treatment (his body weight was 95 kg, and BMI was 28.4 kg/m2). He was offered to introduce aripiprazole, but he refused due to his friend, who was taking it and told him about unknown “adverse effects.” Then, cariprazine was offered, and he agreed to introduce it at an initial dosage of 1.5 mg/day. After three weeks of therapy, a slight improvement on PANSS was seen (total score = 101, positive = 20, negative = 30, general = 61), and the patient reported that he “felt better” especially on functioning and cognitions without adverse effects. The patient agreed to titrate cariprazine up to 3 mg/day. After other two months we observed an improvement of both PANSS (total score = 77, positive = 13, negative = 15, general = 49) and BMI (26.9 kg/m2), and clozapine was reduced to 300 mg/day. The improvement was constant, and he was able to find a job as blue collar in a brick factory as “…my mind and thoughts are more clear…”.
The last observation was conducted in September 2019 after further three months of combination therapy, and the PANSS scores were also improved (total score = 57, positive = 9, negative = 12, general = 29) as well as the BMI (25.6 kg/m2). No adverse effects were reported or observed, and the patient was taking 300 mg/day of clozapine and cariprazine 3 mg/day.
The subject gave us written informed consent for publication of this case report.
DISCUSSION
To date, these were the first cases of cariprazine combination with clozapine in the occurrence of inadequate response to the latter. Cariprazine combination showed a remarkable effect, as demonstrated by a reduction in PANSS scores over time.
Even if the decrease in PANSS scores was observed for all subscales, a noticeable reduction was obtained concerning negative symptoms that are in line with the mechanism of action on D3 of cariprazine [18]. The D3 receptors, structurally similar to the D2 receptor, are auto-receptors able to modulate the phasic dopaminergic activity and linked to cognition, mood, emotions and reward/substance abuse [19]. Therefore, some authors support its potential role as a pro-cognitive agent and effective treatment in the management of negative symptoms of schizophrenia and an enhancer of the working memory as well [20]. Several studies have suggested that cariprazine affinity and action on D3 may explain its efficacy on negative symptoms, executive deficits, cognitive and mood impairment [21,22]. D3 receptors are identified at the asymmetric synapses at the head of dendritic spines, a localization that is in sharp contrast with D1 and D2 receptors, which are both pre-synaptic or spread all over dendrites and dendritic spines in neurons of the caudate putamen and NAc [20,23,24]. Moreover, the high concentration of the D3 receptors in the ventral striatum, as compared to the dorsal part, increases the probability that D3 antagonists may have an antipsychotic action with negligible adverse effects including extrapyramidal side effects and catalepsy [25
-27].
Moreover, even though to a more limited extent, cariprazine also shows partial agonism at the 5HT1A receptors, hence by exerting an antidepressant effect in addition to the antipsychotic effect [28]. These mechanisms may explain the positive impact of the cariprazine-clozapine combination seen in these cases.
It is also possible to hypothesize a pharmacokinetic interaction between cariprazine and clozapine to explain the positive outcome of this combination. Cariprazine primarily undergoes dealkylation, dydroxylation, N-oxidation, and cleavage by CYP3A4 and, to a small degree, by CYP2D6 in hepatic microsomes [29]. Clozapine is mostly metabolized in the liver by the CYP1A2 and CYP1A2 activity is an essential determinant of clozapine dose [30]. Other liver enzymes involved in clozapine metabolism include CYP2D6 and CYP3A4 [31]. As the involvement of CYP3A4 in clozapine metabolism is secondary [32], one may hypothesize that a drug-drug interaction with cariprazine may be unlikely. Unluckily we did not evaluate clozapine blood levels, but none of patients reported symptoms of excessive clozapine dosage. Both patients were administered the maximum tolerated doses of clozapine, and no adverse events were reported.
Besides, we observed a good effect on weight and BMI with a reduction of both parameters with cariprazine combination. This effect may be explained by both cariprazine pro-cognitive action (both of patients started to perform a moderate physical activity) and by the decrease in negative symptoms through the action on D3 receptors [22]. Moreover, cariprazine binds to the 5HT2A (Ki = 19 nM) that may be involved in pro-cognitive activity [33] while it has a lower affinity for 5HT7 (Ki = 111 nM), 5HT2C (Ki = 134 nM) and a1 receptors, by exerting an antagonist action. Its weak action on these receptors may further explain its good metabolic profile [34]. Concerning cariprazine adverse effects [12,35], post hoc analyses of safety data from cariprazine studies in schizophrenia showed a dose-response association for several treatment-emergent adverse events and clinical laboratory values including akathisia, extrapyramidal symptoms, creatine phosphokinase and transaminase elevations, increases in blood pressure, but none of these were observed in our cases.
In conclusion, cariprazine add-on to clozapine showed remarkable and relatively rapid efficacy in the treatment of subjects with inadequate response to clozapine. The tolerability of this association was excellent without reported adverse effects. However, future studies on larger samples are needed to elucidate this positive effect better.
Conflicts of Interest
No potential conflict of interest relevant to this article was reported.
Author Contributions
All the Authors contributed to this case series with equal efforts. | 95 kg. | Weight | CC BY-NC | 33508803 | 19,070,008 | 2021-02-28 |
What was the administration route of drug 'HALOPERIDOL'? | Cariprazine Add-on in Inadequate Clozapine Response: A Report on Two Cases.
Cariprazine is a novel antipsychotic drug that exerts partial agonism of dopamine D2/D3 receptors with preferential binding to the D3 receptor, antagonism of 5HT2B receptors, and partial agonism of 5HT1A. Currently, cariprazine has shown clinical efficacy in patients with schizophrenia and with bipolar disorder, as well as adjunctive treatment in patients with Major Depressive Disorder (MDD) and drug-resistant MDD. In the present case series, we report on two patients with treatment-resistant schizophrenia and partial response to clozapine who benefit from combination with cariprazine. The effects of cariprazine combination were remarkable also concerning the adverse metabolic effects of clozapine.
INTRODUCTION
Schizophrenia is a chronic and devastating disease affecting around 0.5% of the population [1]. It is known that the complete remission or recovery of symptoms is relatively rare in schizophrenia, and the treatment resistance remains one of the most critical challenges in psychiatry [2]. The gold standard in the case of resistant schizophrenia is the clozapine treatment [3]. However, despite the greater efficacy of clozapine over other antipsychotics in the management of resistant schizophrenia, a signifi-cant number of patients fail to attain adequate response or develop clozapine-related adverse effects, and clozapine-resistant schizophrenia represents a challenge for the clinician and a calamity for the patients [4,5].
Cariprazine, also named the “rip” [6], is a novel second-generation antipsychotic with antagonist-partial agonist properties at D2 and D3 receptors, with preferential binding to the D3 receptors [7]. Cariprazine has been approved by the Food and Drug Administration for the treatment of adult patients with schizophrenia (Europe and USA) and acute treatment of manic/ and mixed episodes of bipolar disorder (only USA) [8,9].
Cariprazine acts as an antagonist or partial agonist at D2/D3 receptors, depending on the endogenous dopaminergic tone [10]. At high dopamine levels, it seems to act as an antagonist, while at lower dopamine levels, it exerts its agonist action, by increasing the dopamine receptor activity [11,12]. It preferentially has a 5- to 30-fold greater affinity for human D3 receptors (Ki = 0.085 nM) than for the D2L (Ki = 0.49 nM) and D2S (Ki = 0.69 nM) [13]. Meanwhile, even though to a more limited extent, cariprazine also shows partial agonism at the 5HT1A receptors (Ki = 2.46 nM), hence by exerting an antidepressant effect in addition to the antipsychotic effect [14,15]. Moreover, cariprazine also shows an antagonist at human 5HT2B receptors (Ki = 0.58 nM), which has a crucial role in modulating dopamine release in the nucleus accumbens [16].
Interestingly, besides the positive effects on positive symptoms, cariprazine is associated with improvements in primary negative symptoms of schizophrenia and these improvements are unlikely to result from improved positive or overall symptoms [17].
In the present paper, we report on two cases of treatment-resistant schizophrenia with inadequate response to clozapine who were successfully treated with cariprazine combination in the outpatient facility of Hospital of Teramo, Italy.
CASE
Case 1
She is a 29-year-old unemployed and unmarried woman with a long history of schizophrenia diagnosed when she was 19-year-old with an acute episode characterized by mixed positive and negative symptoms with marked hostility. During the years, she underwent several treatments with both oral (haloperidol, olanzapine, and paliperidone) and long-acting antipsychotics (haloperidol decanoate and aripiprazole long-acting) with no effects on psychopathology. Then, from almost one year, she was switched to clozapine 450 mg/day with an inadequate response, despite a tentative to augment with amisulpride 800 mg/die that was reported ineffective. In fact, at the time of our observation (referred to us by her general practitioner) the patient was symptomatic, and the scores of Positive and Negative Symptoms Scale (PANSS) were still clinically significant (total score = 113, positive = 22, negative = 33, general = 58). Moreover, the patient developed weight gain during clozapine treatment (at the time of our first observation, her body weight was 84 kg, and body mass index [BMI] was 26.8 kg/m2).
Thus, considering the failure of previous treatment with aripiprazole (due to a non response, but without adverse effects), cariprazine combination was offered and introduced at the initial dosage of 1.5 mg in the morning. After a week, cariprazine was titrated to 3 mg/die without adverse effects. After 30 days of cariprazine combination we observed an improvement in PANSS scores (total score = 89, positive = 18, negative = 27, general = 44). After other three months of therapy, the PANSS scores were remarkably improved (total score = 74, positive = 14, negative = 20, general = 40) without adverse effects reported. Moreover, we noted a significant improvement in weight (79 kg) and BMI (25.1 kg/m2).
The last observation was carried out in September 2019, after other four months of combination therapy, and the PANSS scores further improved (total score = 57, positive = 10, negative = 14, general = 33) as well as the BMI (24.6 kg/m2). The patient found a job as a part-time working in handbag manufacture with a reported good yield and performed a regular and moderate physical activity three times a week. No adverse effects were reported or observed, and the patient was taking 400 mg/day of clozapine and cariprazine 3 mg/day.
The subject gave us written informed consent for publication of this case report.
Case 2
He is a 35-year-old blue-collar unmarried man who was diagnosed with schizophrenia at the age of 24-year- old. His onset was accompanied by substance abuse (mainly cocaine and cannabis) and was characterized by positive symptoms, a marked impulse dyscontrol with great hostility and negative symptoms such as blunted affect, social withdrawal, and poor rapport. He was treated in the past with several antipsychotics (haloperidol, olanzapine, and paliperidone long-acting) without response and considerable problem in functioning (the patient lost his job). From almost one year and a half, he was taking clozapine 350 mg/day with a functional improvement only on hostility and uncooperativeness, without significant effects on other symptoms. He was also administered in the past clozapine 400 mg/day, but he developed marked sedation, and the dosage was reduced to 350 mg/day that was well tolerated. He willingly decided to consult us, and at the time of our observation, he was symptomatic, and the scores of PANSS were still clinically significant (total score = 121, positive = 27, negative = 34, general = 70).
Moreover, the patient was overweight even if he was unable to relate this to clozapine treatment (his body weight was 95 kg, and BMI was 28.4 kg/m2). He was offered to introduce aripiprazole, but he refused due to his friend, who was taking it and told him about unknown “adverse effects.” Then, cariprazine was offered, and he agreed to introduce it at an initial dosage of 1.5 mg/day. After three weeks of therapy, a slight improvement on PANSS was seen (total score = 101, positive = 20, negative = 30, general = 61), and the patient reported that he “felt better” especially on functioning and cognitions without adverse effects. The patient agreed to titrate cariprazine up to 3 mg/day. After other two months we observed an improvement of both PANSS (total score = 77, positive = 13, negative = 15, general = 49) and BMI (26.9 kg/m2), and clozapine was reduced to 300 mg/day. The improvement was constant, and he was able to find a job as blue collar in a brick factory as “…my mind and thoughts are more clear…”.
The last observation was conducted in September 2019 after further three months of combination therapy, and the PANSS scores were also improved (total score = 57, positive = 9, negative = 12, general = 29) as well as the BMI (25.6 kg/m2). No adverse effects were reported or observed, and the patient was taking 300 mg/day of clozapine and cariprazine 3 mg/day.
The subject gave us written informed consent for publication of this case report.
DISCUSSION
To date, these were the first cases of cariprazine combination with clozapine in the occurrence of inadequate response to the latter. Cariprazine combination showed a remarkable effect, as demonstrated by a reduction in PANSS scores over time.
Even if the decrease in PANSS scores was observed for all subscales, a noticeable reduction was obtained concerning negative symptoms that are in line with the mechanism of action on D3 of cariprazine [18]. The D3 receptors, structurally similar to the D2 receptor, are auto-receptors able to modulate the phasic dopaminergic activity and linked to cognition, mood, emotions and reward/substance abuse [19]. Therefore, some authors support its potential role as a pro-cognitive agent and effective treatment in the management of negative symptoms of schizophrenia and an enhancer of the working memory as well [20]. Several studies have suggested that cariprazine affinity and action on D3 may explain its efficacy on negative symptoms, executive deficits, cognitive and mood impairment [21,22]. D3 receptors are identified at the asymmetric synapses at the head of dendritic spines, a localization that is in sharp contrast with D1 and D2 receptors, which are both pre-synaptic or spread all over dendrites and dendritic spines in neurons of the caudate putamen and NAc [20,23,24]. Moreover, the high concentration of the D3 receptors in the ventral striatum, as compared to the dorsal part, increases the probability that D3 antagonists may have an antipsychotic action with negligible adverse effects including extrapyramidal side effects and catalepsy [25
-27].
Moreover, even though to a more limited extent, cariprazine also shows partial agonism at the 5HT1A receptors, hence by exerting an antidepressant effect in addition to the antipsychotic effect [28]. These mechanisms may explain the positive impact of the cariprazine-clozapine combination seen in these cases.
It is also possible to hypothesize a pharmacokinetic interaction between cariprazine and clozapine to explain the positive outcome of this combination. Cariprazine primarily undergoes dealkylation, dydroxylation, N-oxidation, and cleavage by CYP3A4 and, to a small degree, by CYP2D6 in hepatic microsomes [29]. Clozapine is mostly metabolized in the liver by the CYP1A2 and CYP1A2 activity is an essential determinant of clozapine dose [30]. Other liver enzymes involved in clozapine metabolism include CYP2D6 and CYP3A4 [31]. As the involvement of CYP3A4 in clozapine metabolism is secondary [32], one may hypothesize that a drug-drug interaction with cariprazine may be unlikely. Unluckily we did not evaluate clozapine blood levels, but none of patients reported symptoms of excessive clozapine dosage. Both patients were administered the maximum tolerated doses of clozapine, and no adverse events were reported.
Besides, we observed a good effect on weight and BMI with a reduction of both parameters with cariprazine combination. This effect may be explained by both cariprazine pro-cognitive action (both of patients started to perform a moderate physical activity) and by the decrease in negative symptoms through the action on D3 receptors [22]. Moreover, cariprazine binds to the 5HT2A (Ki = 19 nM) that may be involved in pro-cognitive activity [33] while it has a lower affinity for 5HT7 (Ki = 111 nM), 5HT2C (Ki = 134 nM) and a1 receptors, by exerting an antagonist action. Its weak action on these receptors may further explain its good metabolic profile [34]. Concerning cariprazine adverse effects [12,35], post hoc analyses of safety data from cariprazine studies in schizophrenia showed a dose-response association for several treatment-emergent adverse events and clinical laboratory values including akathisia, extrapyramidal symptoms, creatine phosphokinase and transaminase elevations, increases in blood pressure, but none of these were observed in our cases.
In conclusion, cariprazine add-on to clozapine showed remarkable and relatively rapid efficacy in the treatment of subjects with inadequate response to clozapine. The tolerability of this association was excellent without reported adverse effects. However, future studies on larger samples are needed to elucidate this positive effect better.
Conflicts of Interest
No potential conflict of interest relevant to this article was reported.
Author Contributions
All the Authors contributed to this case series with equal efforts. | Oral | DrugAdministrationRoute | CC BY-NC | 33508803 | 19,082,683 | 2021-02-28 |
What was the administration route of drug 'OLANZAPINE'? | Cariprazine Add-on in Inadequate Clozapine Response: A Report on Two Cases.
Cariprazine is a novel antipsychotic drug that exerts partial agonism of dopamine D2/D3 receptors with preferential binding to the D3 receptor, antagonism of 5HT2B receptors, and partial agonism of 5HT1A. Currently, cariprazine has shown clinical efficacy in patients with schizophrenia and with bipolar disorder, as well as adjunctive treatment in patients with Major Depressive Disorder (MDD) and drug-resistant MDD. In the present case series, we report on two patients with treatment-resistant schizophrenia and partial response to clozapine who benefit from combination with cariprazine. The effects of cariprazine combination were remarkable also concerning the adverse metabolic effects of clozapine.
INTRODUCTION
Schizophrenia is a chronic and devastating disease affecting around 0.5% of the population [1]. It is known that the complete remission or recovery of symptoms is relatively rare in schizophrenia, and the treatment resistance remains one of the most critical challenges in psychiatry [2]. The gold standard in the case of resistant schizophrenia is the clozapine treatment [3]. However, despite the greater efficacy of clozapine over other antipsychotics in the management of resistant schizophrenia, a signifi-cant number of patients fail to attain adequate response or develop clozapine-related adverse effects, and clozapine-resistant schizophrenia represents a challenge for the clinician and a calamity for the patients [4,5].
Cariprazine, also named the “rip” [6], is a novel second-generation antipsychotic with antagonist-partial agonist properties at D2 and D3 receptors, with preferential binding to the D3 receptors [7]. Cariprazine has been approved by the Food and Drug Administration for the treatment of adult patients with schizophrenia (Europe and USA) and acute treatment of manic/ and mixed episodes of bipolar disorder (only USA) [8,9].
Cariprazine acts as an antagonist or partial agonist at D2/D3 receptors, depending on the endogenous dopaminergic tone [10]. At high dopamine levels, it seems to act as an antagonist, while at lower dopamine levels, it exerts its agonist action, by increasing the dopamine receptor activity [11,12]. It preferentially has a 5- to 30-fold greater affinity for human D3 receptors (Ki = 0.085 nM) than for the D2L (Ki = 0.49 nM) and D2S (Ki = 0.69 nM) [13]. Meanwhile, even though to a more limited extent, cariprazine also shows partial agonism at the 5HT1A receptors (Ki = 2.46 nM), hence by exerting an antidepressant effect in addition to the antipsychotic effect [14,15]. Moreover, cariprazine also shows an antagonist at human 5HT2B receptors (Ki = 0.58 nM), which has a crucial role in modulating dopamine release in the nucleus accumbens [16].
Interestingly, besides the positive effects on positive symptoms, cariprazine is associated with improvements in primary negative symptoms of schizophrenia and these improvements are unlikely to result from improved positive or overall symptoms [17].
In the present paper, we report on two cases of treatment-resistant schizophrenia with inadequate response to clozapine who were successfully treated with cariprazine combination in the outpatient facility of Hospital of Teramo, Italy.
CASE
Case 1
She is a 29-year-old unemployed and unmarried woman with a long history of schizophrenia diagnosed when she was 19-year-old with an acute episode characterized by mixed positive and negative symptoms with marked hostility. During the years, she underwent several treatments with both oral (haloperidol, olanzapine, and paliperidone) and long-acting antipsychotics (haloperidol decanoate and aripiprazole long-acting) with no effects on psychopathology. Then, from almost one year, she was switched to clozapine 450 mg/day with an inadequate response, despite a tentative to augment with amisulpride 800 mg/die that was reported ineffective. In fact, at the time of our observation (referred to us by her general practitioner) the patient was symptomatic, and the scores of Positive and Negative Symptoms Scale (PANSS) were still clinically significant (total score = 113, positive = 22, negative = 33, general = 58). Moreover, the patient developed weight gain during clozapine treatment (at the time of our first observation, her body weight was 84 kg, and body mass index [BMI] was 26.8 kg/m2).
Thus, considering the failure of previous treatment with aripiprazole (due to a non response, but without adverse effects), cariprazine combination was offered and introduced at the initial dosage of 1.5 mg in the morning. After a week, cariprazine was titrated to 3 mg/die without adverse effects. After 30 days of cariprazine combination we observed an improvement in PANSS scores (total score = 89, positive = 18, negative = 27, general = 44). After other three months of therapy, the PANSS scores were remarkably improved (total score = 74, positive = 14, negative = 20, general = 40) without adverse effects reported. Moreover, we noted a significant improvement in weight (79 kg) and BMI (25.1 kg/m2).
The last observation was carried out in September 2019, after other four months of combination therapy, and the PANSS scores further improved (total score = 57, positive = 10, negative = 14, general = 33) as well as the BMI (24.6 kg/m2). The patient found a job as a part-time working in handbag manufacture with a reported good yield and performed a regular and moderate physical activity three times a week. No adverse effects were reported or observed, and the patient was taking 400 mg/day of clozapine and cariprazine 3 mg/day.
The subject gave us written informed consent for publication of this case report.
Case 2
He is a 35-year-old blue-collar unmarried man who was diagnosed with schizophrenia at the age of 24-year- old. His onset was accompanied by substance abuse (mainly cocaine and cannabis) and was characterized by positive symptoms, a marked impulse dyscontrol with great hostility and negative symptoms such as blunted affect, social withdrawal, and poor rapport. He was treated in the past with several antipsychotics (haloperidol, olanzapine, and paliperidone long-acting) without response and considerable problem in functioning (the patient lost his job). From almost one year and a half, he was taking clozapine 350 mg/day with a functional improvement only on hostility and uncooperativeness, without significant effects on other symptoms. He was also administered in the past clozapine 400 mg/day, but he developed marked sedation, and the dosage was reduced to 350 mg/day that was well tolerated. He willingly decided to consult us, and at the time of our observation, he was symptomatic, and the scores of PANSS were still clinically significant (total score = 121, positive = 27, negative = 34, general = 70).
Moreover, the patient was overweight even if he was unable to relate this to clozapine treatment (his body weight was 95 kg, and BMI was 28.4 kg/m2). He was offered to introduce aripiprazole, but he refused due to his friend, who was taking it and told him about unknown “adverse effects.” Then, cariprazine was offered, and he agreed to introduce it at an initial dosage of 1.5 mg/day. After three weeks of therapy, a slight improvement on PANSS was seen (total score = 101, positive = 20, negative = 30, general = 61), and the patient reported that he “felt better” especially on functioning and cognitions without adverse effects. The patient agreed to titrate cariprazine up to 3 mg/day. After other two months we observed an improvement of both PANSS (total score = 77, positive = 13, negative = 15, general = 49) and BMI (26.9 kg/m2), and clozapine was reduced to 300 mg/day. The improvement was constant, and he was able to find a job as blue collar in a brick factory as “…my mind and thoughts are more clear…”.
The last observation was conducted in September 2019 after further three months of combination therapy, and the PANSS scores were also improved (total score = 57, positive = 9, negative = 12, general = 29) as well as the BMI (25.6 kg/m2). No adverse effects were reported or observed, and the patient was taking 300 mg/day of clozapine and cariprazine 3 mg/day.
The subject gave us written informed consent for publication of this case report.
DISCUSSION
To date, these were the first cases of cariprazine combination with clozapine in the occurrence of inadequate response to the latter. Cariprazine combination showed a remarkable effect, as demonstrated by a reduction in PANSS scores over time.
Even if the decrease in PANSS scores was observed for all subscales, a noticeable reduction was obtained concerning negative symptoms that are in line with the mechanism of action on D3 of cariprazine [18]. The D3 receptors, structurally similar to the D2 receptor, are auto-receptors able to modulate the phasic dopaminergic activity and linked to cognition, mood, emotions and reward/substance abuse [19]. Therefore, some authors support its potential role as a pro-cognitive agent and effective treatment in the management of negative symptoms of schizophrenia and an enhancer of the working memory as well [20]. Several studies have suggested that cariprazine affinity and action on D3 may explain its efficacy on negative symptoms, executive deficits, cognitive and mood impairment [21,22]. D3 receptors are identified at the asymmetric synapses at the head of dendritic spines, a localization that is in sharp contrast with D1 and D2 receptors, which are both pre-synaptic or spread all over dendrites and dendritic spines in neurons of the caudate putamen and NAc [20,23,24]. Moreover, the high concentration of the D3 receptors in the ventral striatum, as compared to the dorsal part, increases the probability that D3 antagonists may have an antipsychotic action with negligible adverse effects including extrapyramidal side effects and catalepsy [25
-27].
Moreover, even though to a more limited extent, cariprazine also shows partial agonism at the 5HT1A receptors, hence by exerting an antidepressant effect in addition to the antipsychotic effect [28]. These mechanisms may explain the positive impact of the cariprazine-clozapine combination seen in these cases.
It is also possible to hypothesize a pharmacokinetic interaction between cariprazine and clozapine to explain the positive outcome of this combination. Cariprazine primarily undergoes dealkylation, dydroxylation, N-oxidation, and cleavage by CYP3A4 and, to a small degree, by CYP2D6 in hepatic microsomes [29]. Clozapine is mostly metabolized in the liver by the CYP1A2 and CYP1A2 activity is an essential determinant of clozapine dose [30]. Other liver enzymes involved in clozapine metabolism include CYP2D6 and CYP3A4 [31]. As the involvement of CYP3A4 in clozapine metabolism is secondary [32], one may hypothesize that a drug-drug interaction with cariprazine may be unlikely. Unluckily we did not evaluate clozapine blood levels, but none of patients reported symptoms of excessive clozapine dosage. Both patients were administered the maximum tolerated doses of clozapine, and no adverse events were reported.
Besides, we observed a good effect on weight and BMI with a reduction of both parameters with cariprazine combination. This effect may be explained by both cariprazine pro-cognitive action (both of patients started to perform a moderate physical activity) and by the decrease in negative symptoms through the action on D3 receptors [22]. Moreover, cariprazine binds to the 5HT2A (Ki = 19 nM) that may be involved in pro-cognitive activity [33] while it has a lower affinity for 5HT7 (Ki = 111 nM), 5HT2C (Ki = 134 nM) and a1 receptors, by exerting an antagonist action. Its weak action on these receptors may further explain its good metabolic profile [34]. Concerning cariprazine adverse effects [12,35], post hoc analyses of safety data from cariprazine studies in schizophrenia showed a dose-response association for several treatment-emergent adverse events and clinical laboratory values including akathisia, extrapyramidal symptoms, creatine phosphokinase and transaminase elevations, increases in blood pressure, but none of these were observed in our cases.
In conclusion, cariprazine add-on to clozapine showed remarkable and relatively rapid efficacy in the treatment of subjects with inadequate response to clozapine. The tolerability of this association was excellent without reported adverse effects. However, future studies on larger samples are needed to elucidate this positive effect better.
Conflicts of Interest
No potential conflict of interest relevant to this article was reported.
Author Contributions
All the Authors contributed to this case series with equal efforts. | Oral | DrugAdministrationRoute | CC BY-NC | 33508803 | 19,082,683 | 2021-02-28 |
What was the administration route of drug 'PALIPERIDONE'? | Cariprazine Add-on in Inadequate Clozapine Response: A Report on Two Cases.
Cariprazine is a novel antipsychotic drug that exerts partial agonism of dopamine D2/D3 receptors with preferential binding to the D3 receptor, antagonism of 5HT2B receptors, and partial agonism of 5HT1A. Currently, cariprazine has shown clinical efficacy in patients with schizophrenia and with bipolar disorder, as well as adjunctive treatment in patients with Major Depressive Disorder (MDD) and drug-resistant MDD. In the present case series, we report on two patients with treatment-resistant schizophrenia and partial response to clozapine who benefit from combination with cariprazine. The effects of cariprazine combination were remarkable also concerning the adverse metabolic effects of clozapine.
INTRODUCTION
Schizophrenia is a chronic and devastating disease affecting around 0.5% of the population [1]. It is known that the complete remission or recovery of symptoms is relatively rare in schizophrenia, and the treatment resistance remains one of the most critical challenges in psychiatry [2]. The gold standard in the case of resistant schizophrenia is the clozapine treatment [3]. However, despite the greater efficacy of clozapine over other antipsychotics in the management of resistant schizophrenia, a signifi-cant number of patients fail to attain adequate response or develop clozapine-related adverse effects, and clozapine-resistant schizophrenia represents a challenge for the clinician and a calamity for the patients [4,5].
Cariprazine, also named the “rip” [6], is a novel second-generation antipsychotic with antagonist-partial agonist properties at D2 and D3 receptors, with preferential binding to the D3 receptors [7]. Cariprazine has been approved by the Food and Drug Administration for the treatment of adult patients with schizophrenia (Europe and USA) and acute treatment of manic/ and mixed episodes of bipolar disorder (only USA) [8,9].
Cariprazine acts as an antagonist or partial agonist at D2/D3 receptors, depending on the endogenous dopaminergic tone [10]. At high dopamine levels, it seems to act as an antagonist, while at lower dopamine levels, it exerts its agonist action, by increasing the dopamine receptor activity [11,12]. It preferentially has a 5- to 30-fold greater affinity for human D3 receptors (Ki = 0.085 nM) than for the D2L (Ki = 0.49 nM) and D2S (Ki = 0.69 nM) [13]. Meanwhile, even though to a more limited extent, cariprazine also shows partial agonism at the 5HT1A receptors (Ki = 2.46 nM), hence by exerting an antidepressant effect in addition to the antipsychotic effect [14,15]. Moreover, cariprazine also shows an antagonist at human 5HT2B receptors (Ki = 0.58 nM), which has a crucial role in modulating dopamine release in the nucleus accumbens [16].
Interestingly, besides the positive effects on positive symptoms, cariprazine is associated with improvements in primary negative symptoms of schizophrenia and these improvements are unlikely to result from improved positive or overall symptoms [17].
In the present paper, we report on two cases of treatment-resistant schizophrenia with inadequate response to clozapine who were successfully treated with cariprazine combination in the outpatient facility of Hospital of Teramo, Italy.
CASE
Case 1
She is a 29-year-old unemployed and unmarried woman with a long history of schizophrenia diagnosed when she was 19-year-old with an acute episode characterized by mixed positive and negative symptoms with marked hostility. During the years, she underwent several treatments with both oral (haloperidol, olanzapine, and paliperidone) and long-acting antipsychotics (haloperidol decanoate and aripiprazole long-acting) with no effects on psychopathology. Then, from almost one year, she was switched to clozapine 450 mg/day with an inadequate response, despite a tentative to augment with amisulpride 800 mg/die that was reported ineffective. In fact, at the time of our observation (referred to us by her general practitioner) the patient was symptomatic, and the scores of Positive and Negative Symptoms Scale (PANSS) were still clinically significant (total score = 113, positive = 22, negative = 33, general = 58). Moreover, the patient developed weight gain during clozapine treatment (at the time of our first observation, her body weight was 84 kg, and body mass index [BMI] was 26.8 kg/m2).
Thus, considering the failure of previous treatment with aripiprazole (due to a non response, but without adverse effects), cariprazine combination was offered and introduced at the initial dosage of 1.5 mg in the morning. After a week, cariprazine was titrated to 3 mg/die without adverse effects. After 30 days of cariprazine combination we observed an improvement in PANSS scores (total score = 89, positive = 18, negative = 27, general = 44). After other three months of therapy, the PANSS scores were remarkably improved (total score = 74, positive = 14, negative = 20, general = 40) without adverse effects reported. Moreover, we noted a significant improvement in weight (79 kg) and BMI (25.1 kg/m2).
The last observation was carried out in September 2019, after other four months of combination therapy, and the PANSS scores further improved (total score = 57, positive = 10, negative = 14, general = 33) as well as the BMI (24.6 kg/m2). The patient found a job as a part-time working in handbag manufacture with a reported good yield and performed a regular and moderate physical activity three times a week. No adverse effects were reported or observed, and the patient was taking 400 mg/day of clozapine and cariprazine 3 mg/day.
The subject gave us written informed consent for publication of this case report.
Case 2
He is a 35-year-old blue-collar unmarried man who was diagnosed with schizophrenia at the age of 24-year- old. His onset was accompanied by substance abuse (mainly cocaine and cannabis) and was characterized by positive symptoms, a marked impulse dyscontrol with great hostility and negative symptoms such as blunted affect, social withdrawal, and poor rapport. He was treated in the past with several antipsychotics (haloperidol, olanzapine, and paliperidone long-acting) without response and considerable problem in functioning (the patient lost his job). From almost one year and a half, he was taking clozapine 350 mg/day with a functional improvement only on hostility and uncooperativeness, without significant effects on other symptoms. He was also administered in the past clozapine 400 mg/day, but he developed marked sedation, and the dosage was reduced to 350 mg/day that was well tolerated. He willingly decided to consult us, and at the time of our observation, he was symptomatic, and the scores of PANSS were still clinically significant (total score = 121, positive = 27, negative = 34, general = 70).
Moreover, the patient was overweight even if he was unable to relate this to clozapine treatment (his body weight was 95 kg, and BMI was 28.4 kg/m2). He was offered to introduce aripiprazole, but he refused due to his friend, who was taking it and told him about unknown “adverse effects.” Then, cariprazine was offered, and he agreed to introduce it at an initial dosage of 1.5 mg/day. After three weeks of therapy, a slight improvement on PANSS was seen (total score = 101, positive = 20, negative = 30, general = 61), and the patient reported that he “felt better” especially on functioning and cognitions without adverse effects. The patient agreed to titrate cariprazine up to 3 mg/day. After other two months we observed an improvement of both PANSS (total score = 77, positive = 13, negative = 15, general = 49) and BMI (26.9 kg/m2), and clozapine was reduced to 300 mg/day. The improvement was constant, and he was able to find a job as blue collar in a brick factory as “…my mind and thoughts are more clear…”.
The last observation was conducted in September 2019 after further three months of combination therapy, and the PANSS scores were also improved (total score = 57, positive = 9, negative = 12, general = 29) as well as the BMI (25.6 kg/m2). No adverse effects were reported or observed, and the patient was taking 300 mg/day of clozapine and cariprazine 3 mg/day.
The subject gave us written informed consent for publication of this case report.
DISCUSSION
To date, these were the first cases of cariprazine combination with clozapine in the occurrence of inadequate response to the latter. Cariprazine combination showed a remarkable effect, as demonstrated by a reduction in PANSS scores over time.
Even if the decrease in PANSS scores was observed for all subscales, a noticeable reduction was obtained concerning negative symptoms that are in line with the mechanism of action on D3 of cariprazine [18]. The D3 receptors, structurally similar to the D2 receptor, are auto-receptors able to modulate the phasic dopaminergic activity and linked to cognition, mood, emotions and reward/substance abuse [19]. Therefore, some authors support its potential role as a pro-cognitive agent and effective treatment in the management of negative symptoms of schizophrenia and an enhancer of the working memory as well [20]. Several studies have suggested that cariprazine affinity and action on D3 may explain its efficacy on negative symptoms, executive deficits, cognitive and mood impairment [21,22]. D3 receptors are identified at the asymmetric synapses at the head of dendritic spines, a localization that is in sharp contrast with D1 and D2 receptors, which are both pre-synaptic or spread all over dendrites and dendritic spines in neurons of the caudate putamen and NAc [20,23,24]. Moreover, the high concentration of the D3 receptors in the ventral striatum, as compared to the dorsal part, increases the probability that D3 antagonists may have an antipsychotic action with negligible adverse effects including extrapyramidal side effects and catalepsy [25
-27].
Moreover, even though to a more limited extent, cariprazine also shows partial agonism at the 5HT1A receptors, hence by exerting an antidepressant effect in addition to the antipsychotic effect [28]. These mechanisms may explain the positive impact of the cariprazine-clozapine combination seen in these cases.
It is also possible to hypothesize a pharmacokinetic interaction between cariprazine and clozapine to explain the positive outcome of this combination. Cariprazine primarily undergoes dealkylation, dydroxylation, N-oxidation, and cleavage by CYP3A4 and, to a small degree, by CYP2D6 in hepatic microsomes [29]. Clozapine is mostly metabolized in the liver by the CYP1A2 and CYP1A2 activity is an essential determinant of clozapine dose [30]. Other liver enzymes involved in clozapine metabolism include CYP2D6 and CYP3A4 [31]. As the involvement of CYP3A4 in clozapine metabolism is secondary [32], one may hypothesize that a drug-drug interaction with cariprazine may be unlikely. Unluckily we did not evaluate clozapine blood levels, but none of patients reported symptoms of excessive clozapine dosage. Both patients were administered the maximum tolerated doses of clozapine, and no adverse events were reported.
Besides, we observed a good effect on weight and BMI with a reduction of both parameters with cariprazine combination. This effect may be explained by both cariprazine pro-cognitive action (both of patients started to perform a moderate physical activity) and by the decrease in negative symptoms through the action on D3 receptors [22]. Moreover, cariprazine binds to the 5HT2A (Ki = 19 nM) that may be involved in pro-cognitive activity [33] while it has a lower affinity for 5HT7 (Ki = 111 nM), 5HT2C (Ki = 134 nM) and a1 receptors, by exerting an antagonist action. Its weak action on these receptors may further explain its good metabolic profile [34]. Concerning cariprazine adverse effects [12,35], post hoc analyses of safety data from cariprazine studies in schizophrenia showed a dose-response association for several treatment-emergent adverse events and clinical laboratory values including akathisia, extrapyramidal symptoms, creatine phosphokinase and transaminase elevations, increases in blood pressure, but none of these were observed in our cases.
In conclusion, cariprazine add-on to clozapine showed remarkable and relatively rapid efficacy in the treatment of subjects with inadequate response to clozapine. The tolerability of this association was excellent without reported adverse effects. However, future studies on larger samples are needed to elucidate this positive effect better.
Conflicts of Interest
No potential conflict of interest relevant to this article was reported.
Author Contributions
All the Authors contributed to this case series with equal efforts. | Oral | DrugAdministrationRoute | CC BY-NC | 33508803 | 19,082,683 | 2021-02-28 |
Give an alphabetized list of all active substances of drugs taken by the patient who experienced 'Anaplastic thyroid cancer'. | Combination of Lenvatinib and Pembrolizumab Is an Effective Treatment Option for Anaplastic and Poorly Differentiated Thyroid Carcinoma.
Anaplastic thyroid carcinoma (ATC) and metastatic poorly differentiated thyroid carcinomas (PDTCs) are rare aggressive malignancies with poor overall survival (OS) despite extensive multimodal therapy. These tumors are highly proliferative, with frequently increased tumor mutational burden (TMB) compared with differentiated thyroid carcinomas, and elevated programmed death ligand 1 (PD-L1) levels. These tumor properties implicate responsiveness to antiangiogenic and antiproliferative multikinase inhibitors such as lenvatinib, and immune checkpoint inhibitors such as pembrolizumab. In a retrospective study, we analyzed six patients with metastatic ATC and two patients with PDTC, who received a combination therapy of lenvatinib and pembrolizumab. Lenvatinib was started at 14-24 mg daily and combined with pembrolizumab at a fixed dose of 200 mg every three weeks. Maximum treatment duration with this combination was 40 months, and 3 of 6 ATC patients are still on therapy. Patient tumors were characterized by whole-exome sequencing and PD-L1 expression levels (tumor proportion score [TPS] 1-90%). Best overall response (BOR) within ATCs was 66% complete remissions (4/6 CR), 16% stable disease (1/6 SD), and 16% progressive disease (1/6 PD). BOR within PDTCs was partial remission (PR 2/2). The median progression-free survival was 17.75 months for all patients, and 16.5 months for ATCs, with treatment durations ranging from 1 to 40 months (1, 4, 11, 15, 19, 25, 27, and 40 months). Grade III/IV toxicities developed in 4 of 8 patients, requiring dose reduction/discontinuation of lenvatinib. The median OS was 18.5 months, with three ATC patients being still alive without relapse (40, 27, and 19 months) despite metastatic disease at the time of treatment initiation (UICC and stage IVC). All patients with long-term (>2 years) or complete responses (CRs) had either increased TMB or a PD-L1 TPS >50%. Our results implicate that the combination of lenvatinib and pembrolizumab might be safe and effective in patients with ATC/PDTC and can result in complete and long-term remissions. The combination treatment is now being systematically examined in a phase II clinical trial (Anaplastic Thyroid Carcinoma Lenvatinib Pembrolizumab [ATLEP]) in ATC/PDTC patients.
Introduction
Anaplastic thyroid carcinoma (ATC) is a rare disease with an extremely high mortality rate and a 10-year survival below 5% (1). ATCs grow very fast, infiltrate into cervical structures, such as the esophagus, trachea, or blood vessels, and metastasize to the lung, brain, and bone. Even with extensive multimodal therapy (surgery, external beam radiotherapy, and chemotherapy), the median overall survival (OS) is only 3–5 months (1–3). ATC frequently arises from differentiated thyroid carcinoma (DTC) but can also emerge de novo. Typical molecular features of ATC are mutations in TP53 (54–64%), TERT (61%), KRAS/NRAS (28–43%), BRAF (18–28%), NF1, NF2, PI3K, PTEN, and genes in the WNT signaling pathway (4–9). BRAF/MEK inhibitor combinations (dabrafenib/trametinib) are approved for BRAFV600E-mutated ATCs and have significantly enhanced survival and has high treatment response (overall response rate [ORR] 69%) (10,11). All other locally advanced or metastatic ATCs (about 75%) are individually treated with carboplatin, paclitaxel, or doxorubicin containing chemotherapeutic regimens with very modest ORR (10–20%) lasting only for a few months (progression-free survival [PFS] 3–4 months) (12–15). Poorly differentiated thyroid carcinoma (PDTC) has a more favorable prognosis, with some patients being partially responsive to radioiodine therapy (RIT), but 10-year survival is also below 10%.
Compared with DTC, ATC/PDTC are characterized by an elevated tumor mutation burden, higher programmed death ligand 1 (PD-L1) levels, and increased neoangiogenesis (VEGFR/FGFR signaling) (7,16–22), suggesting that they may be sensitivity to immune checkpoint and neoangiogenesis inhibitors.
Lenvatinib is an antiangiogenic (VEGFR 1–3/FGFR 1–4) and antiproliferative (RET/PDGFR) tyrosine kinase inhibitor (TKI), which is approved for DTC refractory to radioiodine treatment (23). PFS in DTC is 19.4 months (23–26), but it is reduced to 14.8 months in PDTC, and all patients ultimately develop treatment resistance or treatment intolerance (26). In ATC, the PFS is even shorter (5.6–7.4 months) with variable ORR between 17.4% and 43%, depending on the initial tumor stage (27–29).
Pembrolizumab is an immune checkpoint inhibitor targeting PD-1 on immune cells. Response to pembrolizumab treatment is associated with elevated expression of PD-L1 or high tumor mutational burden (TMB) (30–34). DTC have low TMB and low PD-L1 expression (CPS/TPS) and hence have low response rates to immune checkpoint inhibitor treatments (ORR 9%) (35). In ATC with higher PD-L1/TMB, the effect of immune checkpoint inhibitors is still low (ORR <10%) (36,37), as the slow response to treatment (>8 weeks) cannot keep pace with the aggressive tumor growth.
In vitro studies and mouse experiments indicate synergism between lenvatinib and pembrolizumab (38). Lenvatinib not only blocks tumor neoangiogenesis and proliferation but also enhances immune cell invasion into the tumor and therefore fosters immune responses induced by immune checkpoint inhibitors (38). Furthermore, phase II trials with the lenvatinib/pembrolizumab combination in patients with extensively pretreated metastatic solid tumors (renal, ovarian, and endometrial carcinoma) not only showed acceptable toxicity but also very promising response rates (84% partial response [PR], 16% stable disease [SD]). Phase II/III trials for endometrial, head and neck, and hepatocellular carcinoma validated the high efficacy and safety for this combination (39–42). In ATC, pembrolizumab treatment was used as a salvage strategy after patients had failed lenvatinib or dabrafenib monotherapy or a dabrafenib/trametinib combination therapy. Pembrolizumab was added to the respective TKI and induced PR rates of 43%, but with a very short PFS of only 2.96 months (43).
In contrast to this study, we directly combined lenvatinib and pembrolizumab as front-line therapy after chemotherapy failure in eight patients with metastatic ATC (n = 6) or PDTC (n = 2) and examined treatment outcome and biomarkers for this approach.
Materials and Methods
Study population and patient characteristics
This is a retrospective, single-center (University Medical Center Freiburg) cohort study of eight patients with metastatic ATC (n = 6) or PDTC (n = 2) treated with a combination of the multikinase inhibitor lenvatinib and the immune checkpoint inhibitor pembrolizumab (L/P). Patient data were collected from March 2016 to December 2019 (Table 1). ATC/PDTC diagnosis was histopathologically confirmed by the Institute for Pathology, Freiburg, in all patients. Patients had no BRAFV600E mutation, but numerous other mutations were present (Supplementary Table S1). All patients were pretreated with irradiation, chemotherapy, or RIT (Table 1 and Supplementary Table S2). Adverse events (AEs) were reported according to the National Cancer Institute Common Terminology Criteria for Adverse Events (CTCAE version 5)–GBG (Table 2). The retrospective study was approved by the Institutional Review Board (IRB) of the University Freiburg.
Table 1. Baseline Characteristics
Median age at treatment start (range), years 63.5 (49–88)
Sex, n (%)
Men 4 (50)
Women 4 (50)
Performance status, n (%)
ECOG 0 3 (37.5)
ECOG 1 3 (37.5)
ECOG 2 2 (25)
Pathological diagnosis, n (%)
ATC 6 (75)
PDTC 2 (25)
Location of metastases, n (%)
Lung 8 (100)
Bone 2 (25)
Kidney 1 (12.5)
Brain 1 (12.5)
Liver 1 (12.5)
Skin 1 (12.5)
Cervical relapse, n (%) 6 (75)
Previous therapy, n (%)
Surgery 8 (100)
Radiation ± chemosensitizing 7 (87.5)
Chemotherapy 6 (75)
RIT 2 (25)
ATC, anaplastic thyroid carcinoma; ECOG, Eastern Cooperative Oncology Group; PDTC, poorly differentiated thyroid carcinoma; RIT, radioiodine therapy.
Table 2. Adverse Events According to the Common Terminology Criteria for Adverse Events Version 5.0
Event Grade I/II (%) Grade III/IV (%)
Total 8/8 (100) 3/8 (36)
Hypertension 5/8 (63)
Fatigue 2/8 (25) 1/8 (13)
Anorexia 2/8 (25) 2/8 (25)
Oral mucositis 2/8 (25)
Joint/muscle pain 1/8 (13)
Hand–foot syndrome 1/8 (13)
Diarrhea 1/8 (13)
Proteinuria 1/8 (13)
Abdominal pain 1/8 (13)
Cervical bleeding 1/8 (13)
Data are given as totals and %. Events reported are listed in descending frequency of columns for grade I/II and grade III/IV. A patients with several multiple occurrences of an adverse event is counted only once with the highest grade. A patient with multiple adverse events is counted only once in the total row.
Treatment strategy
Patients started with lenvatinib 24 mg oral daily if the body weight (BW) was more than 80 kg, or 20 mg for BW less than 80 kg. Pembrolizumab infusions were started in between 1 and 4 weeks after initiation of lenvatinib at a fixed dose of 200 mg total every 3 weeks. Dose for lenvatinib was stepwise reduced upon occurrence of side effects according to clinical judgment. Lenvatinib was given at least for 1 year and was then stopped in patients with confirmed complete response (CR). Pembrolizumab was given for up to 40 months. It will be continued in all patients reaching a CR for two more years.
Response assessment
Radiology assessment including cervical, chest, and abdominal computed tomography (CT) scans was performed before treatment and then every 3–4 months. Response to therapy was determined centrally using the RECIST 1.1 criteria (Fig. 1A and Supplementary Table S3). Positron emission tomography (PET)–CT using [18F] fluorodeoxyglucose (FDG) (PET/CT) was performed before treatment, and after 12–16 months of treatment to confirm CRs (the European Organisation for Research and Treatment of Cancer [EORTC] response criteria for PET). In case of persistent lesions without tracer uptake on PET/CT (PR according to the RECIST 1.1 [CT scan], but CR according to the EORTC criteria for PET), lesions were surgically removed (1/8) to confirm the absence of viable tumor tissue (pathological CR criteria, Supplementary Table S4).
FIG. 1. (A) ORR after 3–4 months of treatment, 6/8 PR, 1/8 SD, 1/8 PD. (B) BOR within 16 months of treatment. (C) Lenvatinib dosage and changes over time. (D) Treatment duration and ongoing treatment. Patients in CR. BOR, best overall response; CR, complete response; ORR, overall response rate; PD, progressive disease; PR, partial response; SD, stable disease.
The efficacy of the combination treatment was assessed by ORR 3–4 months after starting treatment, best overall response (BOR) (Fig. 1B), PFS, and OS. PFS was defined as the time elapsed between starting treatment and progression or death, whichever occurred first. OS was defined as the time between starting treatment and death.
Molecular testing and immunohistochemistry
Molecular testing by whole-exome sequencing (WES) was performed from formalin-fixed and paraffin-embedded tissue specimens at the Deutsches Krebsforschungszentrum Heidelberg (DKFZ) as described previously (44,45). PD-L1 status was determined by immunohistochemistry (antibody clone SP263; Ventana) in tumor tissue specimens obtained at initial diagnosis before treatment. The tumor proportion score (TPS) was determined as proportion of PD-L1-positive tumor cells of 100 tumor cells. The combined proportion score (CPS), as amount of PD-L1-positive tumor and immune cells within 100 tumor cells, was also determined centrally at the Department of Pathology of the University Medical Center Freiburg.
Statistical analysis
Kaplan–Meier curves were used for OS and PFS. Descriptive statistics were used to summarize patients' characteristics and AEs. Statistical analysis was performed using IBM SPSS Statistics version 25.
Results
Eight patients with metastatic ATC (n = 6) or PDTC (n = 2) were treated with a combination of lenvatinib and pembrolizumab after failing chemotherapy, irradiation, or RIT (Table 1 and Supplementary Table S2). All the 8 patients had been extensively pretreated with surgery (8/8), local cervical external beam radiation therapy (6/8), RIT (2/2), local cerebral irradiation therapy (1/8), or systemic chemotherapy alone (6/8) (carboplatin/paclitaxel [4/8], cisplatin/paclitaxel [1/8], cisplatin/doxorubicin [1/8], and paclitaxel only [1/8]) (Table 1 and Supplementary Table S2). The median patient age was 66.4 years. At the beginning of treatment with lenvatinib/pembrolizumab, all patients had stage IVC. All patients had lung metastasis (8/8), and 2 of 8 skeletal metastasis, 1 of 8 liver metastasis, 1 of 8 kidney metastasis, 1 of 8 skin metastasis, and 1 of 8 brain metastasis. Six of eight patients also had progression of their local tumor. Eastern Cooperative Oncology Group (ECOG) performance status ranged from 0 to 2, with 3 ECOG 0 (38%), 3 ECOG 1 (38%), and 2 ECOG 2 (25%). Molecular diagnostics showed that none of the patients had a BRAFV600E mutation, but numerous other mutations typical for ATC/PDTC were detected and are listed in Supplementary Table S1.
Treatment regimen and AEs
Lenvatinib was started at a daily dose of 24 mg in 5 of 8 patients (BW more than 80 kg) and 20 mg in 2 patients with bodyweight less than 80 kg. An 88-year-old woman started on 14 mg/day (Fig. 1C and Table 3). Pembrolizumab treatment was initiated after a median of 2.7 weeks (ranging from 1 to 4 weeks after starting lenvatinib) and was given i.v. at a fixed dose of 200 mg every 3 weeks. In general, the therapy was well tolerated with the predominant grade II to IV AEs (AEs according to the CTCAE) being hypertension (5/8), fatigue (4/8), weight loss/anorexia (3/8), oral mucositis (2/8), diarrhea (2/8), joint/muscle pain (1/8), and hand–foot syndrome (1/8) (Table 2). The lenvatinib dose was reduced stepwise upon occurrence of intolerable side effects from 24 to 20, 14, 12, and 10 mg/day (Fig. 1C). Most side effects resolved after reducing the dose of lenvatinib, but in two patients, lenvatinib-induced AEs required treatment discontinuation (patients 3 and 6, Table 3). One grade IV serious adverse event (SAE) with a lethal cervical bleeding occurred after removal of the tracheostomy in patient 5 despite being in complete remission (Tables 2 and 3).
Table 3. Patient History
Patient Entity Age, years Prior treatment ORR in 3/4 months BOR CT+PET PFS, months OS, months Adverse events (CTCAE in grade °) Median dose lenvatinib, mg/day Current therapy/ outcome
1 PDTC 63 S Rx C/T PR PR 25 27 Hypertension °II
Fatigue °II
Anorexia °I
Oral mucositis °I 24 PD/death after stopping lenvatinib due to a knee surgery
2 ATC 76 S Rx C/T PR CR 40 40 Hypertension °II
Anorexia °II 24 Alive, CR after 12 months lenvatinib/pembrolizumab, now without treatment
3 PDTC 49 S RIT C/T PR PR 15 23 Anorexia °III
Abdominal pain °III 14 PD/death, lenvatinib on/off due to weight loss/abdominal pain
4 ATC 68 S Rx C/T PR CR 26 26 Anorexia °I
Loss of appetite °II
Proteinuria °I
Hypertension °II 20 Alive, CR after 10 months of treatment, now pembrolizumab mono
5 ATC 63 S Rx C/T PR CR 11 11 Diarrhea °II
Hypertension °II
Cervical bleeding °IV 20 CR after 7 months of treatment. Death due to cervical bleeding
6 ATC 88 S Rx C/T SD SD 4 7 Diarrhea °II
Anorexia °III
Proteinuria °II
Fatigue °III
Oral mucositis °II 14 PD/death after stopping medication due to side effects
7 ATC 64 S RIT Rx PR CR 19 19 Hypertension °II
Fatigue °II
Joint pain °II
Hand–foot syndrome °I 24 Alive, CR, lenvatinib/pembrolizumab for 12 months, now pembrolizumab mono
8 ATC 60 S R C/T PD PD 1 1 Hypertension °II 24 PD/death due to cervical tumor progression
Patient characteristics including diagnosis, previous therapy (S, RIT, Rx, C/T), patient age, PFS, ORR, BOR, OS, response after 3 months, maximum response, main side effects, median dose lenvatinib in mg/day, dose pembrolizumab, current treatment/outcome. CTCAE grades in roman numbers. Responses were assessed via the RECIST v1.1 radiology assessment and FDG uptake according to the EORTC criteria for PET.
BOR, best overall response; C/T, chemotherapy; CT, computed tomography; CR, complete response; CTCAE, Common Terminology Criteria for Adverse Events; FDG, [18F] fluorodeoxyglucose; ORR, overall response rate; OS, overall survival; PD, progressive disease; PET, positron emission tomography; PFS, progression free survival; PR, partial response; Rx, radiation therapy; S, surgery; SD, stable disease.
After four months of treatment, lenvatinib/pembrolizumab was discontinued due to severe weight loss/anorexia (grade III) in the 88-year-old patient (patient 6), and she died due to disease progression three months later. One patient was intolerant to lenvatinib treatment due to grade III abdominal pain and weight loss/anorexia (patient 3). Lenvatinib was reduced from 24 to 20 to 14 and 12 mg/day in a stepwise manner, and after 14 months, lenvatinib/pembrolizumab treatment was discontinued. Two patients received the full dose of lenvatinib 24 mg for 24 months (Fig. 1C). Pembrolizumab was given for up to 40 months and will be continued in all patients reaching a CR for two more years (Fig. 1D).
Treatment efficacy
Treatment response was first assessed 3–4 months after lenvatinib/pembrolizumab treatment. Six of eight patients had a PR according to the RECIST v1.1 criteria (Fig. 1A). ORR for ATCs was 66% (4/6 PR). The 88-year-old patient (ATC) at 14 mg lenvatinib had SD (patient 6). One ATC patient (patient 8) did not respond to lenvatinib/pembrolizumab treatment combination and died within the first month of treatment due to cervical tumor progression (1/8 progressive disease) (Fig. 1A and Supplementary Data).
BOR changed in four ATC patients from PR to CR within 16 months of treatment (total CR rate 50%, CR rate for ATC 66%) (Fig. 1B). Individual patient history is summarized in the Supplementary Data. ATC patient 2 had a confirmed CR for all target- and nontarget lesions 16 months after lenvatinib/pembrolizumab treatment, and stopped taking lenvatinib after 2 years (24 mg daily for 24 months), but continued pembrolizumab for 16 more months (40 months total). He stopped treatment for 6 months and is still in CR. ATC patient 4 with lung and brain metastases had a PR 12 months after starting treatment, but all lesions in the lung were without FDG uptake (CR according to the EORTC criteria for PET). All lung lesions were surgically removed and showed a pathological CR (no viable tumor cells). Therefore, the patient was judged as having a CR and has discontinued lenvatinib after 1 year of treatment, and continues with pembrolizumab only (26 months total). Patient 7 with a massive neck tumor and lung metastasis had a PET/CT confirmed CR 12 months after starting treatment. He stopped lenvatinib after 15 months and now continues with pembrolizumab only (19 months total). ATC patient 5 had confirmed CR 10 months after treatment start, but unfortunately died due to bleeding complications after removal of the tracheostomy tube (Table 3 and Supplementary Table S2).
Treatment durations ranged from 1 to 40 months (ATC: 40, 26, 19, 18, 4, and 1 month; PDTC: 25 and 15 months, respectively), with three patients being treated for more than 2 years (Fig. 1D). At the time of data cutoff, 3 of 8 patients (patients 2, 4, and 7, all ATCs) were still alive and on therapy (40, 26, and 19 months). We stopped the treatment of patient 2 after 40 months of treatment, and he is now regularly monitored by CT scans every 3 months. The other patients died due to disease progression (2/6 ATC, 2/2 PDTC) or hemorrhage (grade IV SAE, patient 5, Table 3). ATC patient 8 was resistant to the treatment. ATC patients 1 and 6 died shortly after discontinuation of the lenvatinib treatment caused by lenvatinib intolerance in patient 6 (grade III anorexia), and because lenvatinib had to be discontinued due to an infectious complication after a knee surgery in patient 1 (Table 3). The median PFS for the total cohort was 17.6 months, and the median OS was 19 months (Fig. 2). Data analysis for ATC only showed a median PFS of 16.8 months and a median OS of 17.3 months (Fig. 2).
FIG. 2. Kaplan–Meier curves for ATCs only and total patients. (A) PFS in all patients and ATC only. (B) OS in all patients and ATC only. ATC, anaplastic thyroid carcinoma; OS, overall survival; PFS, progression-free survival.
Biomarkers
To assess potential predictors of treatment response, we investigated the PD-L1 expression of the tumor cells and macrophages/immune cells. Furthermore, WES was performed in 7 of 8 patients, and sequences were compared to germ line sequences to assess somatic mutations and the TMB. In 1 patient (1/8), targeted sequencing for 11 frequently mutated genes (Supplementary Table S1) was performed due to low material. All tumors were positive for PD-L1 expression with a TPS ranging from 1% to 90%, and 5 of 8 patients with TPS >50% (Table 4). The CPS ranged from 5 to 100 (Table 4). Interestingly, the ATC patient with the lowest TPS (1%) and CPS 5 did not respond to the treatment (patient 8). In contrast, the patients with responses lasting more than two years and those achieving a CR all had PD-L1 TPS >50% (5/8), a CPS >75 (3/8), or a high mutation frequency above 5 mutations per megabase (3/8). The patient (patient 2) with the highest number of mutations (>1400 somatic mutations) has the longest CR duration (30 months).
Table 4. Biomarker Analysis
Patient ORR after 3/4 months (RECIST 1.1) BOR (CT/MRI/PET-CT) Response according to PET-CT TPS, % CPS Somatic mutations TMB (mutations/Mb)
1 PR PR PR 50 40 106 13.79
2 PR CR CR 60 75 1447 81.87
3 PR PR PR 10 10 79 4.08
4 PR CR CR 90 100 19 3
5 PR CR n.a. 80 100 29 3.3
6 SD SD n.a. 60 65 24 3.58
7 PR CR CR 5 7 138 5.59
8 PD PD n.a. 1 5 n.a. n.a.
CPS, combined proportion score; MRI, magnet resonance tomography; n.a., not applicable; TMB, tumor mutation burden; TPS, tumor proportion score.
Discussion
Current treatment options for ATC are limited, and response rates are low and short-lived, with marginal to absent CR (13,14). Only the small proportion of BRAFV600E-mutated ATC (about 20%) can be effectively treated with a BRAF/MEK inhibitor combination of dabrafenib and trametinib (10,11), but for the other 70–80% of ATCs, no treatment options are approved after chemotherapy failure in most countries.
ATC and PDTC are characterized by a very high proliferation rate and tumor invasiveness, driven by concurrent mutations in several pro-proliferative pathways (RAS, WNT, loss of TP53), and strongly activated VEGF/FGF signaling. PD-L1 and TMB are upregulated, but the response to single immune checkpoint inhibition often comes too late and is overrun by the aggressiveness of the disease (36).
While many kinase inhibitors (sorafenib/pazopanib) failed to show treatment efficacy in ATC (30–32), lenvatinib trials demonstrated some promising effects, with 17.4–43% PRs and up to 50% SD (27–29). CRs were absent and PFS lasted only between 77 days and 7.4 months (27–29). Besides its fast, but short-lived antiproliferative effects, lenvatinib was shown to improve immune responses to immune checkpoint inhibitors in mice. Therefore, by combining both agents, we aimed to use lenvatinib as a fast and effective bridging treatment and immuno-sensitizer for the immune checkpoint inhibitor pembrolizumab in ATC/PDTC patients.
In contrast to single-agent therapy, the combination of lenvatinib and pembrolizumab was highly effective in our treatment cohort. Eight ATC/PDTC patients who had previously been treated with several lines of therapy including chemotherapy, chemoirradiation, and even single immune checkpoint inhibition (1/8) received a combination of lenvatinib and pembrolizumab for a maximum of 40 months. The combination treatment was well tolerated and could be sustained over one year in half of the patients, and even over two years in 37% (3/8) of the patients. Half of the ATC patients (3/6) were still on therapy at data cutoff with no sustained grade III/IV toxicities despite having initially metastatic disease; three patients had confirmed CR by PET/CT and/or histopathologic examination of former metastatic sites. Seventy-five percent of all patients and 66% of the ATC patients reached a PR/CR within 16 months of treatment. The remission rates observed with lenvatinib/pembrolizumab combination in ATC/PDTC are similar to previously published data for other heavily pretreated solid tumors, such as patients with head and neck tumors, endometrial, renal cell, or hepatocellular carcinoma (39–42). As CRs and long-lasting remissions were rarely observed in ATC patients treated with lenvatinib only (27–29), the addition of pembrolizumab is most likely inducing this effect.
In patients who are already resistant to TKI treatment, the addition of pembrolizumab is only partially functional with a PFS of only 2.96 months (43), which indicates that the up-front combination of lenvatinib and pembrolizumab might be much more effective than using these drugs sequentially.
TMB and PD-L1 expression levels (TPS/CPS) are independent biomarkers for response to immune checkpoint inhibitors in solid tumors (30,46,47). In our analysis, patients reaching a CR or those who had long-term remission over two years all had a TPS above 50%, a CPS higher than 75, and/or a TMB >5/MB, indicating that those may be biomarkers for response to lenvatinib/pembrolizumab treatment in ATC/PDTC.
In general, the combination of lenvatinib and pembrolizumab was well tolerated even in the elderly patients with a higher ECOG performance status. Results are encouraging with an ORR of 75%, including a CR rate of 50% (66% in ATCs) and responses over 2 years. Therefore, the treatment results and biomarkers will be further evaluated in a phase II clinical trial with lenvatinib and pembrolizumab in ATC/PDTC patients (ATLEP trial, Anaplastic Thyroid Carcinoma Lenvatinib Pembrolizumab, EudraCT No. 2017-004570-34).
Supplementary Material
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Acknowledgments
Thanks to our patients and relatives for their support for this study. Thanks to Prof. Roland Mertelsmann for his continuous support and wisdom. Thanks to the molecular tumor board and the CCCF for their support.
Authors' Contributions
C.D., J.S., C.M., O.T., H.W., and N.B. wrote the article. J.R., C.K., and P.T.M. performed and evaluated PET/CTs. K.A., and S.K. performed PD-L1 staining and evaluation. M.R. designed figures. M.B. and P.M. analyzed WES data. A.Z., P.R., M.K., C.W., T.S., C.S., C.M., C.K., N.B., and K.L. treated patients and revised the article.
Author Disclosure Statement
C.D. received honoraria and travel costs for consultancy role at Eisai, AbbVie, and Gilead. M.K. received honoraria and travel costs for consultancy role at Eisai GmbH. A.Z. received honoraria and travel costs for consultancy role at Eisai, J&J, and Merck and participates in the Keynote 158 trial.
Funding Information
Resarch funding grant for IIT trials from the University of Freiburg.
Supplementary Material
Supplementary Data
Supplementary Table S1
Supplementary Table S2
Supplementary Table S3
Supplementary Table S4 | CARBOPLATIN, PACLITAXEL | DrugsGivenReaction | CC BY | 33509020 | 20,559,976 | 2021-07 |
Give an alphabetized list of all active substances of drugs taken by the patient who experienced 'Malignant neoplasm progression'. | Combination of Lenvatinib and Pembrolizumab Is an Effective Treatment Option for Anaplastic and Poorly Differentiated Thyroid Carcinoma.
Anaplastic thyroid carcinoma (ATC) and metastatic poorly differentiated thyroid carcinomas (PDTCs) are rare aggressive malignancies with poor overall survival (OS) despite extensive multimodal therapy. These tumors are highly proliferative, with frequently increased tumor mutational burden (TMB) compared with differentiated thyroid carcinomas, and elevated programmed death ligand 1 (PD-L1) levels. These tumor properties implicate responsiveness to antiangiogenic and antiproliferative multikinase inhibitors such as lenvatinib, and immune checkpoint inhibitors such as pembrolizumab. In a retrospective study, we analyzed six patients with metastatic ATC and two patients with PDTC, who received a combination therapy of lenvatinib and pembrolizumab. Lenvatinib was started at 14-24 mg daily and combined with pembrolizumab at a fixed dose of 200 mg every three weeks. Maximum treatment duration with this combination was 40 months, and 3 of 6 ATC patients are still on therapy. Patient tumors were characterized by whole-exome sequencing and PD-L1 expression levels (tumor proportion score [TPS] 1-90%). Best overall response (BOR) within ATCs was 66% complete remissions (4/6 CR), 16% stable disease (1/6 SD), and 16% progressive disease (1/6 PD). BOR within PDTCs was partial remission (PR 2/2). The median progression-free survival was 17.75 months for all patients, and 16.5 months for ATCs, with treatment durations ranging from 1 to 40 months (1, 4, 11, 15, 19, 25, 27, and 40 months). Grade III/IV toxicities developed in 4 of 8 patients, requiring dose reduction/discontinuation of lenvatinib. The median OS was 18.5 months, with three ATC patients being still alive without relapse (40, 27, and 19 months) despite metastatic disease at the time of treatment initiation (UICC and stage IVC). All patients with long-term (>2 years) or complete responses (CRs) had either increased TMB or a PD-L1 TPS >50%. Our results implicate that the combination of lenvatinib and pembrolizumab might be safe and effective in patients with ATC/PDTC and can result in complete and long-term remissions. The combination treatment is now being systematically examined in a phase II clinical trial (Anaplastic Thyroid Carcinoma Lenvatinib Pembrolizumab [ATLEP]) in ATC/PDTC patients.
Introduction
Anaplastic thyroid carcinoma (ATC) is a rare disease with an extremely high mortality rate and a 10-year survival below 5% (1). ATCs grow very fast, infiltrate into cervical structures, such as the esophagus, trachea, or blood vessels, and metastasize to the lung, brain, and bone. Even with extensive multimodal therapy (surgery, external beam radiotherapy, and chemotherapy), the median overall survival (OS) is only 3–5 months (1–3). ATC frequently arises from differentiated thyroid carcinoma (DTC) but can also emerge de novo. Typical molecular features of ATC are mutations in TP53 (54–64%), TERT (61%), KRAS/NRAS (28–43%), BRAF (18–28%), NF1, NF2, PI3K, PTEN, and genes in the WNT signaling pathway (4–9). BRAF/MEK inhibitor combinations (dabrafenib/trametinib) are approved for BRAFV600E-mutated ATCs and have significantly enhanced survival and has high treatment response (overall response rate [ORR] 69%) (10,11). All other locally advanced or metastatic ATCs (about 75%) are individually treated with carboplatin, paclitaxel, or doxorubicin containing chemotherapeutic regimens with very modest ORR (10–20%) lasting only for a few months (progression-free survival [PFS] 3–4 months) (12–15). Poorly differentiated thyroid carcinoma (PDTC) has a more favorable prognosis, with some patients being partially responsive to radioiodine therapy (RIT), but 10-year survival is also below 10%.
Compared with DTC, ATC/PDTC are characterized by an elevated tumor mutation burden, higher programmed death ligand 1 (PD-L1) levels, and increased neoangiogenesis (VEGFR/FGFR signaling) (7,16–22), suggesting that they may be sensitivity to immune checkpoint and neoangiogenesis inhibitors.
Lenvatinib is an antiangiogenic (VEGFR 1–3/FGFR 1–4) and antiproliferative (RET/PDGFR) tyrosine kinase inhibitor (TKI), which is approved for DTC refractory to radioiodine treatment (23). PFS in DTC is 19.4 months (23–26), but it is reduced to 14.8 months in PDTC, and all patients ultimately develop treatment resistance or treatment intolerance (26). In ATC, the PFS is even shorter (5.6–7.4 months) with variable ORR between 17.4% and 43%, depending on the initial tumor stage (27–29).
Pembrolizumab is an immune checkpoint inhibitor targeting PD-1 on immune cells. Response to pembrolizumab treatment is associated with elevated expression of PD-L1 or high tumor mutational burden (TMB) (30–34). DTC have low TMB and low PD-L1 expression (CPS/TPS) and hence have low response rates to immune checkpoint inhibitor treatments (ORR 9%) (35). In ATC with higher PD-L1/TMB, the effect of immune checkpoint inhibitors is still low (ORR <10%) (36,37), as the slow response to treatment (>8 weeks) cannot keep pace with the aggressive tumor growth.
In vitro studies and mouse experiments indicate synergism between lenvatinib and pembrolizumab (38). Lenvatinib not only blocks tumor neoangiogenesis and proliferation but also enhances immune cell invasion into the tumor and therefore fosters immune responses induced by immune checkpoint inhibitors (38). Furthermore, phase II trials with the lenvatinib/pembrolizumab combination in patients with extensively pretreated metastatic solid tumors (renal, ovarian, and endometrial carcinoma) not only showed acceptable toxicity but also very promising response rates (84% partial response [PR], 16% stable disease [SD]). Phase II/III trials for endometrial, head and neck, and hepatocellular carcinoma validated the high efficacy and safety for this combination (39–42). In ATC, pembrolizumab treatment was used as a salvage strategy after patients had failed lenvatinib or dabrafenib monotherapy or a dabrafenib/trametinib combination therapy. Pembrolizumab was added to the respective TKI and induced PR rates of 43%, but with a very short PFS of only 2.96 months (43).
In contrast to this study, we directly combined lenvatinib and pembrolizumab as front-line therapy after chemotherapy failure in eight patients with metastatic ATC (n = 6) or PDTC (n = 2) and examined treatment outcome and biomarkers for this approach.
Materials and Methods
Study population and patient characteristics
This is a retrospective, single-center (University Medical Center Freiburg) cohort study of eight patients with metastatic ATC (n = 6) or PDTC (n = 2) treated with a combination of the multikinase inhibitor lenvatinib and the immune checkpoint inhibitor pembrolizumab (L/P). Patient data were collected from March 2016 to December 2019 (Table 1). ATC/PDTC diagnosis was histopathologically confirmed by the Institute for Pathology, Freiburg, in all patients. Patients had no BRAFV600E mutation, but numerous other mutations were present (Supplementary Table S1). All patients were pretreated with irradiation, chemotherapy, or RIT (Table 1 and Supplementary Table S2). Adverse events (AEs) were reported according to the National Cancer Institute Common Terminology Criteria for Adverse Events (CTCAE version 5)–GBG (Table 2). The retrospective study was approved by the Institutional Review Board (IRB) of the University Freiburg.
Table 1. Baseline Characteristics
Median age at treatment start (range), years 63.5 (49–88)
Sex, n (%)
Men 4 (50)
Women 4 (50)
Performance status, n (%)
ECOG 0 3 (37.5)
ECOG 1 3 (37.5)
ECOG 2 2 (25)
Pathological diagnosis, n (%)
ATC 6 (75)
PDTC 2 (25)
Location of metastases, n (%)
Lung 8 (100)
Bone 2 (25)
Kidney 1 (12.5)
Brain 1 (12.5)
Liver 1 (12.5)
Skin 1 (12.5)
Cervical relapse, n (%) 6 (75)
Previous therapy, n (%)
Surgery 8 (100)
Radiation ± chemosensitizing 7 (87.5)
Chemotherapy 6 (75)
RIT 2 (25)
ATC, anaplastic thyroid carcinoma; ECOG, Eastern Cooperative Oncology Group; PDTC, poorly differentiated thyroid carcinoma; RIT, radioiodine therapy.
Table 2. Adverse Events According to the Common Terminology Criteria for Adverse Events Version 5.0
Event Grade I/II (%) Grade III/IV (%)
Total 8/8 (100) 3/8 (36)
Hypertension 5/8 (63)
Fatigue 2/8 (25) 1/8 (13)
Anorexia 2/8 (25) 2/8 (25)
Oral mucositis 2/8 (25)
Joint/muscle pain 1/8 (13)
Hand–foot syndrome 1/8 (13)
Diarrhea 1/8 (13)
Proteinuria 1/8 (13)
Abdominal pain 1/8 (13)
Cervical bleeding 1/8 (13)
Data are given as totals and %. Events reported are listed in descending frequency of columns for grade I/II and grade III/IV. A patients with several multiple occurrences of an adverse event is counted only once with the highest grade. A patient with multiple adverse events is counted only once in the total row.
Treatment strategy
Patients started with lenvatinib 24 mg oral daily if the body weight (BW) was more than 80 kg, or 20 mg for BW less than 80 kg. Pembrolizumab infusions were started in between 1 and 4 weeks after initiation of lenvatinib at a fixed dose of 200 mg total every 3 weeks. Dose for lenvatinib was stepwise reduced upon occurrence of side effects according to clinical judgment. Lenvatinib was given at least for 1 year and was then stopped in patients with confirmed complete response (CR). Pembrolizumab was given for up to 40 months. It will be continued in all patients reaching a CR for two more years.
Response assessment
Radiology assessment including cervical, chest, and abdominal computed tomography (CT) scans was performed before treatment and then every 3–4 months. Response to therapy was determined centrally using the RECIST 1.1 criteria (Fig. 1A and Supplementary Table S3). Positron emission tomography (PET)–CT using [18F] fluorodeoxyglucose (FDG) (PET/CT) was performed before treatment, and after 12–16 months of treatment to confirm CRs (the European Organisation for Research and Treatment of Cancer [EORTC] response criteria for PET). In case of persistent lesions without tracer uptake on PET/CT (PR according to the RECIST 1.1 [CT scan], but CR according to the EORTC criteria for PET), lesions were surgically removed (1/8) to confirm the absence of viable tumor tissue (pathological CR criteria, Supplementary Table S4).
FIG. 1. (A) ORR after 3–4 months of treatment, 6/8 PR, 1/8 SD, 1/8 PD. (B) BOR within 16 months of treatment. (C) Lenvatinib dosage and changes over time. (D) Treatment duration and ongoing treatment. Patients in CR. BOR, best overall response; CR, complete response; ORR, overall response rate; PD, progressive disease; PR, partial response; SD, stable disease.
The efficacy of the combination treatment was assessed by ORR 3–4 months after starting treatment, best overall response (BOR) (Fig. 1B), PFS, and OS. PFS was defined as the time elapsed between starting treatment and progression or death, whichever occurred first. OS was defined as the time between starting treatment and death.
Molecular testing and immunohistochemistry
Molecular testing by whole-exome sequencing (WES) was performed from formalin-fixed and paraffin-embedded tissue specimens at the Deutsches Krebsforschungszentrum Heidelberg (DKFZ) as described previously (44,45). PD-L1 status was determined by immunohistochemistry (antibody clone SP263; Ventana) in tumor tissue specimens obtained at initial diagnosis before treatment. The tumor proportion score (TPS) was determined as proportion of PD-L1-positive tumor cells of 100 tumor cells. The combined proportion score (CPS), as amount of PD-L1-positive tumor and immune cells within 100 tumor cells, was also determined centrally at the Department of Pathology of the University Medical Center Freiburg.
Statistical analysis
Kaplan–Meier curves were used for OS and PFS. Descriptive statistics were used to summarize patients' characteristics and AEs. Statistical analysis was performed using IBM SPSS Statistics version 25.
Results
Eight patients with metastatic ATC (n = 6) or PDTC (n = 2) were treated with a combination of lenvatinib and pembrolizumab after failing chemotherapy, irradiation, or RIT (Table 1 and Supplementary Table S2). All the 8 patients had been extensively pretreated with surgery (8/8), local cervical external beam radiation therapy (6/8), RIT (2/2), local cerebral irradiation therapy (1/8), or systemic chemotherapy alone (6/8) (carboplatin/paclitaxel [4/8], cisplatin/paclitaxel [1/8], cisplatin/doxorubicin [1/8], and paclitaxel only [1/8]) (Table 1 and Supplementary Table S2). The median patient age was 66.4 years. At the beginning of treatment with lenvatinib/pembrolizumab, all patients had stage IVC. All patients had lung metastasis (8/8), and 2 of 8 skeletal metastasis, 1 of 8 liver metastasis, 1 of 8 kidney metastasis, 1 of 8 skin metastasis, and 1 of 8 brain metastasis. Six of eight patients also had progression of their local tumor. Eastern Cooperative Oncology Group (ECOG) performance status ranged from 0 to 2, with 3 ECOG 0 (38%), 3 ECOG 1 (38%), and 2 ECOG 2 (25%). Molecular diagnostics showed that none of the patients had a BRAFV600E mutation, but numerous other mutations typical for ATC/PDTC were detected and are listed in Supplementary Table S1.
Treatment regimen and AEs
Lenvatinib was started at a daily dose of 24 mg in 5 of 8 patients (BW more than 80 kg) and 20 mg in 2 patients with bodyweight less than 80 kg. An 88-year-old woman started on 14 mg/day (Fig. 1C and Table 3). Pembrolizumab treatment was initiated after a median of 2.7 weeks (ranging from 1 to 4 weeks after starting lenvatinib) and was given i.v. at a fixed dose of 200 mg every 3 weeks. In general, the therapy was well tolerated with the predominant grade II to IV AEs (AEs according to the CTCAE) being hypertension (5/8), fatigue (4/8), weight loss/anorexia (3/8), oral mucositis (2/8), diarrhea (2/8), joint/muscle pain (1/8), and hand–foot syndrome (1/8) (Table 2). The lenvatinib dose was reduced stepwise upon occurrence of intolerable side effects from 24 to 20, 14, 12, and 10 mg/day (Fig. 1C). Most side effects resolved after reducing the dose of lenvatinib, but in two patients, lenvatinib-induced AEs required treatment discontinuation (patients 3 and 6, Table 3). One grade IV serious adverse event (SAE) with a lethal cervical bleeding occurred after removal of the tracheostomy in patient 5 despite being in complete remission (Tables 2 and 3).
Table 3. Patient History
Patient Entity Age, years Prior treatment ORR in 3/4 months BOR CT+PET PFS, months OS, months Adverse events (CTCAE in grade °) Median dose lenvatinib, mg/day Current therapy/ outcome
1 PDTC 63 S Rx C/T PR PR 25 27 Hypertension °II
Fatigue °II
Anorexia °I
Oral mucositis °I 24 PD/death after stopping lenvatinib due to a knee surgery
2 ATC 76 S Rx C/T PR CR 40 40 Hypertension °II
Anorexia °II 24 Alive, CR after 12 months lenvatinib/pembrolizumab, now without treatment
3 PDTC 49 S RIT C/T PR PR 15 23 Anorexia °III
Abdominal pain °III 14 PD/death, lenvatinib on/off due to weight loss/abdominal pain
4 ATC 68 S Rx C/T PR CR 26 26 Anorexia °I
Loss of appetite °II
Proteinuria °I
Hypertension °II 20 Alive, CR after 10 months of treatment, now pembrolizumab mono
5 ATC 63 S Rx C/T PR CR 11 11 Diarrhea °II
Hypertension °II
Cervical bleeding °IV 20 CR after 7 months of treatment. Death due to cervical bleeding
6 ATC 88 S Rx C/T SD SD 4 7 Diarrhea °II
Anorexia °III
Proteinuria °II
Fatigue °III
Oral mucositis °II 14 PD/death after stopping medication due to side effects
7 ATC 64 S RIT Rx PR CR 19 19 Hypertension °II
Fatigue °II
Joint pain °II
Hand–foot syndrome °I 24 Alive, CR, lenvatinib/pembrolizumab for 12 months, now pembrolizumab mono
8 ATC 60 S R C/T PD PD 1 1 Hypertension °II 24 PD/death due to cervical tumor progression
Patient characteristics including diagnosis, previous therapy (S, RIT, Rx, C/T), patient age, PFS, ORR, BOR, OS, response after 3 months, maximum response, main side effects, median dose lenvatinib in mg/day, dose pembrolizumab, current treatment/outcome. CTCAE grades in roman numbers. Responses were assessed via the RECIST v1.1 radiology assessment and FDG uptake according to the EORTC criteria for PET.
BOR, best overall response; C/T, chemotherapy; CT, computed tomography; CR, complete response; CTCAE, Common Terminology Criteria for Adverse Events; FDG, [18F] fluorodeoxyglucose; ORR, overall response rate; OS, overall survival; PD, progressive disease; PET, positron emission tomography; PFS, progression free survival; PR, partial response; Rx, radiation therapy; S, surgery; SD, stable disease.
After four months of treatment, lenvatinib/pembrolizumab was discontinued due to severe weight loss/anorexia (grade III) in the 88-year-old patient (patient 6), and she died due to disease progression three months later. One patient was intolerant to lenvatinib treatment due to grade III abdominal pain and weight loss/anorexia (patient 3). Lenvatinib was reduced from 24 to 20 to 14 and 12 mg/day in a stepwise manner, and after 14 months, lenvatinib/pembrolizumab treatment was discontinued. Two patients received the full dose of lenvatinib 24 mg for 24 months (Fig. 1C). Pembrolizumab was given for up to 40 months and will be continued in all patients reaching a CR for two more years (Fig. 1D).
Treatment efficacy
Treatment response was first assessed 3–4 months after lenvatinib/pembrolizumab treatment. Six of eight patients had a PR according to the RECIST v1.1 criteria (Fig. 1A). ORR for ATCs was 66% (4/6 PR). The 88-year-old patient (ATC) at 14 mg lenvatinib had SD (patient 6). One ATC patient (patient 8) did not respond to lenvatinib/pembrolizumab treatment combination and died within the first month of treatment due to cervical tumor progression (1/8 progressive disease) (Fig. 1A and Supplementary Data).
BOR changed in four ATC patients from PR to CR within 16 months of treatment (total CR rate 50%, CR rate for ATC 66%) (Fig. 1B). Individual patient history is summarized in the Supplementary Data. ATC patient 2 had a confirmed CR for all target- and nontarget lesions 16 months after lenvatinib/pembrolizumab treatment, and stopped taking lenvatinib after 2 years (24 mg daily for 24 months), but continued pembrolizumab for 16 more months (40 months total). He stopped treatment for 6 months and is still in CR. ATC patient 4 with lung and brain metastases had a PR 12 months after starting treatment, but all lesions in the lung were without FDG uptake (CR according to the EORTC criteria for PET). All lung lesions were surgically removed and showed a pathological CR (no viable tumor cells). Therefore, the patient was judged as having a CR and has discontinued lenvatinib after 1 year of treatment, and continues with pembrolizumab only (26 months total). Patient 7 with a massive neck tumor and lung metastasis had a PET/CT confirmed CR 12 months after starting treatment. He stopped lenvatinib after 15 months and now continues with pembrolizumab only (19 months total). ATC patient 5 had confirmed CR 10 months after treatment start, but unfortunately died due to bleeding complications after removal of the tracheostomy tube (Table 3 and Supplementary Table S2).
Treatment durations ranged from 1 to 40 months (ATC: 40, 26, 19, 18, 4, and 1 month; PDTC: 25 and 15 months, respectively), with three patients being treated for more than 2 years (Fig. 1D). At the time of data cutoff, 3 of 8 patients (patients 2, 4, and 7, all ATCs) were still alive and on therapy (40, 26, and 19 months). We stopped the treatment of patient 2 after 40 months of treatment, and he is now regularly monitored by CT scans every 3 months. The other patients died due to disease progression (2/6 ATC, 2/2 PDTC) or hemorrhage (grade IV SAE, patient 5, Table 3). ATC patient 8 was resistant to the treatment. ATC patients 1 and 6 died shortly after discontinuation of the lenvatinib treatment caused by lenvatinib intolerance in patient 6 (grade III anorexia), and because lenvatinib had to be discontinued due to an infectious complication after a knee surgery in patient 1 (Table 3). The median PFS for the total cohort was 17.6 months, and the median OS was 19 months (Fig. 2). Data analysis for ATC only showed a median PFS of 16.8 months and a median OS of 17.3 months (Fig. 2).
FIG. 2. Kaplan–Meier curves for ATCs only and total patients. (A) PFS in all patients and ATC only. (B) OS in all patients and ATC only. ATC, anaplastic thyroid carcinoma; OS, overall survival; PFS, progression-free survival.
Biomarkers
To assess potential predictors of treatment response, we investigated the PD-L1 expression of the tumor cells and macrophages/immune cells. Furthermore, WES was performed in 7 of 8 patients, and sequences were compared to germ line sequences to assess somatic mutations and the TMB. In 1 patient (1/8), targeted sequencing for 11 frequently mutated genes (Supplementary Table S1) was performed due to low material. All tumors were positive for PD-L1 expression with a TPS ranging from 1% to 90%, and 5 of 8 patients with TPS >50% (Table 4). The CPS ranged from 5 to 100 (Table 4). Interestingly, the ATC patient with the lowest TPS (1%) and CPS 5 did not respond to the treatment (patient 8). In contrast, the patients with responses lasting more than two years and those achieving a CR all had PD-L1 TPS >50% (5/8), a CPS >75 (3/8), or a high mutation frequency above 5 mutations per megabase (3/8). The patient (patient 2) with the highest number of mutations (>1400 somatic mutations) has the longest CR duration (30 months).
Table 4. Biomarker Analysis
Patient ORR after 3/4 months (RECIST 1.1) BOR (CT/MRI/PET-CT) Response according to PET-CT TPS, % CPS Somatic mutations TMB (mutations/Mb)
1 PR PR PR 50 40 106 13.79
2 PR CR CR 60 75 1447 81.87
3 PR PR PR 10 10 79 4.08
4 PR CR CR 90 100 19 3
5 PR CR n.a. 80 100 29 3.3
6 SD SD n.a. 60 65 24 3.58
7 PR CR CR 5 7 138 5.59
8 PD PD n.a. 1 5 n.a. n.a.
CPS, combined proportion score; MRI, magnet resonance tomography; n.a., not applicable; TMB, tumor mutation burden; TPS, tumor proportion score.
Discussion
Current treatment options for ATC are limited, and response rates are low and short-lived, with marginal to absent CR (13,14). Only the small proportion of BRAFV600E-mutated ATC (about 20%) can be effectively treated with a BRAF/MEK inhibitor combination of dabrafenib and trametinib (10,11), but for the other 70–80% of ATCs, no treatment options are approved after chemotherapy failure in most countries.
ATC and PDTC are characterized by a very high proliferation rate and tumor invasiveness, driven by concurrent mutations in several pro-proliferative pathways (RAS, WNT, loss of TP53), and strongly activated VEGF/FGF signaling. PD-L1 and TMB are upregulated, but the response to single immune checkpoint inhibition often comes too late and is overrun by the aggressiveness of the disease (36).
While many kinase inhibitors (sorafenib/pazopanib) failed to show treatment efficacy in ATC (30–32), lenvatinib trials demonstrated some promising effects, with 17.4–43% PRs and up to 50% SD (27–29). CRs were absent and PFS lasted only between 77 days and 7.4 months (27–29). Besides its fast, but short-lived antiproliferative effects, lenvatinib was shown to improve immune responses to immune checkpoint inhibitors in mice. Therefore, by combining both agents, we aimed to use lenvatinib as a fast and effective bridging treatment and immuno-sensitizer for the immune checkpoint inhibitor pembrolizumab in ATC/PDTC patients.
In contrast to single-agent therapy, the combination of lenvatinib and pembrolizumab was highly effective in our treatment cohort. Eight ATC/PDTC patients who had previously been treated with several lines of therapy including chemotherapy, chemoirradiation, and even single immune checkpoint inhibition (1/8) received a combination of lenvatinib and pembrolizumab for a maximum of 40 months. The combination treatment was well tolerated and could be sustained over one year in half of the patients, and even over two years in 37% (3/8) of the patients. Half of the ATC patients (3/6) were still on therapy at data cutoff with no sustained grade III/IV toxicities despite having initially metastatic disease; three patients had confirmed CR by PET/CT and/or histopathologic examination of former metastatic sites. Seventy-five percent of all patients and 66% of the ATC patients reached a PR/CR within 16 months of treatment. The remission rates observed with lenvatinib/pembrolizumab combination in ATC/PDTC are similar to previously published data for other heavily pretreated solid tumors, such as patients with head and neck tumors, endometrial, renal cell, or hepatocellular carcinoma (39–42). As CRs and long-lasting remissions were rarely observed in ATC patients treated with lenvatinib only (27–29), the addition of pembrolizumab is most likely inducing this effect.
In patients who are already resistant to TKI treatment, the addition of pembrolizumab is only partially functional with a PFS of only 2.96 months (43), which indicates that the up-front combination of lenvatinib and pembrolizumab might be much more effective than using these drugs sequentially.
TMB and PD-L1 expression levels (TPS/CPS) are independent biomarkers for response to immune checkpoint inhibitors in solid tumors (30,46,47). In our analysis, patients reaching a CR or those who had long-term remission over two years all had a TPS above 50%, a CPS higher than 75, and/or a TMB >5/MB, indicating that those may be biomarkers for response to lenvatinib/pembrolizumab treatment in ATC/PDTC.
In general, the combination of lenvatinib and pembrolizumab was well tolerated even in the elderly patients with a higher ECOG performance status. Results are encouraging with an ORR of 75%, including a CR rate of 50% (66% in ATCs) and responses over 2 years. Therefore, the treatment results and biomarkers will be further evaluated in a phase II clinical trial with lenvatinib and pembrolizumab in ATC/PDTC patients (ATLEP trial, Anaplastic Thyroid Carcinoma Lenvatinib Pembrolizumab, EudraCT No. 2017-004570-34).
Supplementary Material
Supplemental data
Supplemental data
Supplemental data
Supplemental data
Supplemental data
Acknowledgments
Thanks to our patients and relatives for their support for this study. Thanks to Prof. Roland Mertelsmann for his continuous support and wisdom. Thanks to the molecular tumor board and the CCCF for their support.
Authors' Contributions
C.D., J.S., C.M., O.T., H.W., and N.B. wrote the article. J.R., C.K., and P.T.M. performed and evaluated PET/CTs. K.A., and S.K. performed PD-L1 staining and evaluation. M.R. designed figures. M.B. and P.M. analyzed WES data. A.Z., P.R., M.K., C.W., T.S., C.S., C.M., C.K., N.B., and K.L. treated patients and revised the article.
Author Disclosure Statement
C.D. received honoraria and travel costs for consultancy role at Eisai, AbbVie, and Gilead. M.K. received honoraria and travel costs for consultancy role at Eisai GmbH. A.Z. received honoraria and travel costs for consultancy role at Eisai, J&J, and Merck and participates in the Keynote 158 trial.
Funding Information
Resarch funding grant for IIT trials from the University of Freiburg.
Supplementary Material
Supplementary Data
Supplementary Table S1
Supplementary Table S2
Supplementary Table S3
Supplementary Table S4 | CARBOPLATIN, PACLITAXEL | DrugsGivenReaction | CC BY | 33509020 | 20,554,496 | 2021-07 |
Give an alphabetized list of all active substances of drugs taken by the patient who experienced 'Metastases to bone'. | Combination of Lenvatinib and Pembrolizumab Is an Effective Treatment Option for Anaplastic and Poorly Differentiated Thyroid Carcinoma.
Anaplastic thyroid carcinoma (ATC) and metastatic poorly differentiated thyroid carcinomas (PDTCs) are rare aggressive malignancies with poor overall survival (OS) despite extensive multimodal therapy. These tumors are highly proliferative, with frequently increased tumor mutational burden (TMB) compared with differentiated thyroid carcinomas, and elevated programmed death ligand 1 (PD-L1) levels. These tumor properties implicate responsiveness to antiangiogenic and antiproliferative multikinase inhibitors such as lenvatinib, and immune checkpoint inhibitors such as pembrolizumab. In a retrospective study, we analyzed six patients with metastatic ATC and two patients with PDTC, who received a combination therapy of lenvatinib and pembrolizumab. Lenvatinib was started at 14-24 mg daily and combined with pembrolizumab at a fixed dose of 200 mg every three weeks. Maximum treatment duration with this combination was 40 months, and 3 of 6 ATC patients are still on therapy. Patient tumors were characterized by whole-exome sequencing and PD-L1 expression levels (tumor proportion score [TPS] 1-90%). Best overall response (BOR) within ATCs was 66% complete remissions (4/6 CR), 16% stable disease (1/6 SD), and 16% progressive disease (1/6 PD). BOR within PDTCs was partial remission (PR 2/2). The median progression-free survival was 17.75 months for all patients, and 16.5 months for ATCs, with treatment durations ranging from 1 to 40 months (1, 4, 11, 15, 19, 25, 27, and 40 months). Grade III/IV toxicities developed in 4 of 8 patients, requiring dose reduction/discontinuation of lenvatinib. The median OS was 18.5 months, with three ATC patients being still alive without relapse (40, 27, and 19 months) despite metastatic disease at the time of treatment initiation (UICC and stage IVC). All patients with long-term (>2 years) or complete responses (CRs) had either increased TMB or a PD-L1 TPS >50%. Our results implicate that the combination of lenvatinib and pembrolizumab might be safe and effective in patients with ATC/PDTC and can result in complete and long-term remissions. The combination treatment is now being systematically examined in a phase II clinical trial (Anaplastic Thyroid Carcinoma Lenvatinib Pembrolizumab [ATLEP]) in ATC/PDTC patients.
Introduction
Anaplastic thyroid carcinoma (ATC) is a rare disease with an extremely high mortality rate and a 10-year survival below 5% (1). ATCs grow very fast, infiltrate into cervical structures, such as the esophagus, trachea, or blood vessels, and metastasize to the lung, brain, and bone. Even with extensive multimodal therapy (surgery, external beam radiotherapy, and chemotherapy), the median overall survival (OS) is only 3–5 months (1–3). ATC frequently arises from differentiated thyroid carcinoma (DTC) but can also emerge de novo. Typical molecular features of ATC are mutations in TP53 (54–64%), TERT (61%), KRAS/NRAS (28–43%), BRAF (18–28%), NF1, NF2, PI3K, PTEN, and genes in the WNT signaling pathway (4–9). BRAF/MEK inhibitor combinations (dabrafenib/trametinib) are approved for BRAFV600E-mutated ATCs and have significantly enhanced survival and has high treatment response (overall response rate [ORR] 69%) (10,11). All other locally advanced or metastatic ATCs (about 75%) are individually treated with carboplatin, paclitaxel, or doxorubicin containing chemotherapeutic regimens with very modest ORR (10–20%) lasting only for a few months (progression-free survival [PFS] 3–4 months) (12–15). Poorly differentiated thyroid carcinoma (PDTC) has a more favorable prognosis, with some patients being partially responsive to radioiodine therapy (RIT), but 10-year survival is also below 10%.
Compared with DTC, ATC/PDTC are characterized by an elevated tumor mutation burden, higher programmed death ligand 1 (PD-L1) levels, and increased neoangiogenesis (VEGFR/FGFR signaling) (7,16–22), suggesting that they may be sensitivity to immune checkpoint and neoangiogenesis inhibitors.
Lenvatinib is an antiangiogenic (VEGFR 1–3/FGFR 1–4) and antiproliferative (RET/PDGFR) tyrosine kinase inhibitor (TKI), which is approved for DTC refractory to radioiodine treatment (23). PFS in DTC is 19.4 months (23–26), but it is reduced to 14.8 months in PDTC, and all patients ultimately develop treatment resistance or treatment intolerance (26). In ATC, the PFS is even shorter (5.6–7.4 months) with variable ORR between 17.4% and 43%, depending on the initial tumor stage (27–29).
Pembrolizumab is an immune checkpoint inhibitor targeting PD-1 on immune cells. Response to pembrolizumab treatment is associated with elevated expression of PD-L1 or high tumor mutational burden (TMB) (30–34). DTC have low TMB and low PD-L1 expression (CPS/TPS) and hence have low response rates to immune checkpoint inhibitor treatments (ORR 9%) (35). In ATC with higher PD-L1/TMB, the effect of immune checkpoint inhibitors is still low (ORR <10%) (36,37), as the slow response to treatment (>8 weeks) cannot keep pace with the aggressive tumor growth.
In vitro studies and mouse experiments indicate synergism between lenvatinib and pembrolizumab (38). Lenvatinib not only blocks tumor neoangiogenesis and proliferation but also enhances immune cell invasion into the tumor and therefore fosters immune responses induced by immune checkpoint inhibitors (38). Furthermore, phase II trials with the lenvatinib/pembrolizumab combination in patients with extensively pretreated metastatic solid tumors (renal, ovarian, and endometrial carcinoma) not only showed acceptable toxicity but also very promising response rates (84% partial response [PR], 16% stable disease [SD]). Phase II/III trials for endometrial, head and neck, and hepatocellular carcinoma validated the high efficacy and safety for this combination (39–42). In ATC, pembrolizumab treatment was used as a salvage strategy after patients had failed lenvatinib or dabrafenib monotherapy or a dabrafenib/trametinib combination therapy. Pembrolizumab was added to the respective TKI and induced PR rates of 43%, but with a very short PFS of only 2.96 months (43).
In contrast to this study, we directly combined lenvatinib and pembrolizumab as front-line therapy after chemotherapy failure in eight patients with metastatic ATC (n = 6) or PDTC (n = 2) and examined treatment outcome and biomarkers for this approach.
Materials and Methods
Study population and patient characteristics
This is a retrospective, single-center (University Medical Center Freiburg) cohort study of eight patients with metastatic ATC (n = 6) or PDTC (n = 2) treated with a combination of the multikinase inhibitor lenvatinib and the immune checkpoint inhibitor pembrolizumab (L/P). Patient data were collected from March 2016 to December 2019 (Table 1). ATC/PDTC diagnosis was histopathologically confirmed by the Institute for Pathology, Freiburg, in all patients. Patients had no BRAFV600E mutation, but numerous other mutations were present (Supplementary Table S1). All patients were pretreated with irradiation, chemotherapy, or RIT (Table 1 and Supplementary Table S2). Adverse events (AEs) were reported according to the National Cancer Institute Common Terminology Criteria for Adverse Events (CTCAE version 5)–GBG (Table 2). The retrospective study was approved by the Institutional Review Board (IRB) of the University Freiburg.
Table 1. Baseline Characteristics
Median age at treatment start (range), years 63.5 (49–88)
Sex, n (%)
Men 4 (50)
Women 4 (50)
Performance status, n (%)
ECOG 0 3 (37.5)
ECOG 1 3 (37.5)
ECOG 2 2 (25)
Pathological diagnosis, n (%)
ATC 6 (75)
PDTC 2 (25)
Location of metastases, n (%)
Lung 8 (100)
Bone 2 (25)
Kidney 1 (12.5)
Brain 1 (12.5)
Liver 1 (12.5)
Skin 1 (12.5)
Cervical relapse, n (%) 6 (75)
Previous therapy, n (%)
Surgery 8 (100)
Radiation ± chemosensitizing 7 (87.5)
Chemotherapy 6 (75)
RIT 2 (25)
ATC, anaplastic thyroid carcinoma; ECOG, Eastern Cooperative Oncology Group; PDTC, poorly differentiated thyroid carcinoma; RIT, radioiodine therapy.
Table 2. Adverse Events According to the Common Terminology Criteria for Adverse Events Version 5.0
Event Grade I/II (%) Grade III/IV (%)
Total 8/8 (100) 3/8 (36)
Hypertension 5/8 (63)
Fatigue 2/8 (25) 1/8 (13)
Anorexia 2/8 (25) 2/8 (25)
Oral mucositis 2/8 (25)
Joint/muscle pain 1/8 (13)
Hand–foot syndrome 1/8 (13)
Diarrhea 1/8 (13)
Proteinuria 1/8 (13)
Abdominal pain 1/8 (13)
Cervical bleeding 1/8 (13)
Data are given as totals and %. Events reported are listed in descending frequency of columns for grade I/II and grade III/IV. A patients with several multiple occurrences of an adverse event is counted only once with the highest grade. A patient with multiple adverse events is counted only once in the total row.
Treatment strategy
Patients started with lenvatinib 24 mg oral daily if the body weight (BW) was more than 80 kg, or 20 mg for BW less than 80 kg. Pembrolizumab infusions were started in between 1 and 4 weeks after initiation of lenvatinib at a fixed dose of 200 mg total every 3 weeks. Dose for lenvatinib was stepwise reduced upon occurrence of side effects according to clinical judgment. Lenvatinib was given at least for 1 year and was then stopped in patients with confirmed complete response (CR). Pembrolizumab was given for up to 40 months. It will be continued in all patients reaching a CR for two more years.
Response assessment
Radiology assessment including cervical, chest, and abdominal computed tomography (CT) scans was performed before treatment and then every 3–4 months. Response to therapy was determined centrally using the RECIST 1.1 criteria (Fig. 1A and Supplementary Table S3). Positron emission tomography (PET)–CT using [18F] fluorodeoxyglucose (FDG) (PET/CT) was performed before treatment, and after 12–16 months of treatment to confirm CRs (the European Organisation for Research and Treatment of Cancer [EORTC] response criteria for PET). In case of persistent lesions without tracer uptake on PET/CT (PR according to the RECIST 1.1 [CT scan], but CR according to the EORTC criteria for PET), lesions were surgically removed (1/8) to confirm the absence of viable tumor tissue (pathological CR criteria, Supplementary Table S4).
FIG. 1. (A) ORR after 3–4 months of treatment, 6/8 PR, 1/8 SD, 1/8 PD. (B) BOR within 16 months of treatment. (C) Lenvatinib dosage and changes over time. (D) Treatment duration and ongoing treatment. Patients in CR. BOR, best overall response; CR, complete response; ORR, overall response rate; PD, progressive disease; PR, partial response; SD, stable disease.
The efficacy of the combination treatment was assessed by ORR 3–4 months after starting treatment, best overall response (BOR) (Fig. 1B), PFS, and OS. PFS was defined as the time elapsed between starting treatment and progression or death, whichever occurred first. OS was defined as the time between starting treatment and death.
Molecular testing and immunohistochemistry
Molecular testing by whole-exome sequencing (WES) was performed from formalin-fixed and paraffin-embedded tissue specimens at the Deutsches Krebsforschungszentrum Heidelberg (DKFZ) as described previously (44,45). PD-L1 status was determined by immunohistochemistry (antibody clone SP263; Ventana) in tumor tissue specimens obtained at initial diagnosis before treatment. The tumor proportion score (TPS) was determined as proportion of PD-L1-positive tumor cells of 100 tumor cells. The combined proportion score (CPS), as amount of PD-L1-positive tumor and immune cells within 100 tumor cells, was also determined centrally at the Department of Pathology of the University Medical Center Freiburg.
Statistical analysis
Kaplan–Meier curves were used for OS and PFS. Descriptive statistics were used to summarize patients' characteristics and AEs. Statistical analysis was performed using IBM SPSS Statistics version 25.
Results
Eight patients with metastatic ATC (n = 6) or PDTC (n = 2) were treated with a combination of lenvatinib and pembrolizumab after failing chemotherapy, irradiation, or RIT (Table 1 and Supplementary Table S2). All the 8 patients had been extensively pretreated with surgery (8/8), local cervical external beam radiation therapy (6/8), RIT (2/2), local cerebral irradiation therapy (1/8), or systemic chemotherapy alone (6/8) (carboplatin/paclitaxel [4/8], cisplatin/paclitaxel [1/8], cisplatin/doxorubicin [1/8], and paclitaxel only [1/8]) (Table 1 and Supplementary Table S2). The median patient age was 66.4 years. At the beginning of treatment with lenvatinib/pembrolizumab, all patients had stage IVC. All patients had lung metastasis (8/8), and 2 of 8 skeletal metastasis, 1 of 8 liver metastasis, 1 of 8 kidney metastasis, 1 of 8 skin metastasis, and 1 of 8 brain metastasis. Six of eight patients also had progression of their local tumor. Eastern Cooperative Oncology Group (ECOG) performance status ranged from 0 to 2, with 3 ECOG 0 (38%), 3 ECOG 1 (38%), and 2 ECOG 2 (25%). Molecular diagnostics showed that none of the patients had a BRAFV600E mutation, but numerous other mutations typical for ATC/PDTC were detected and are listed in Supplementary Table S1.
Treatment regimen and AEs
Lenvatinib was started at a daily dose of 24 mg in 5 of 8 patients (BW more than 80 kg) and 20 mg in 2 patients with bodyweight less than 80 kg. An 88-year-old woman started on 14 mg/day (Fig. 1C and Table 3). Pembrolizumab treatment was initiated after a median of 2.7 weeks (ranging from 1 to 4 weeks after starting lenvatinib) and was given i.v. at a fixed dose of 200 mg every 3 weeks. In general, the therapy was well tolerated with the predominant grade II to IV AEs (AEs according to the CTCAE) being hypertension (5/8), fatigue (4/8), weight loss/anorexia (3/8), oral mucositis (2/8), diarrhea (2/8), joint/muscle pain (1/8), and hand–foot syndrome (1/8) (Table 2). The lenvatinib dose was reduced stepwise upon occurrence of intolerable side effects from 24 to 20, 14, 12, and 10 mg/day (Fig. 1C). Most side effects resolved after reducing the dose of lenvatinib, but in two patients, lenvatinib-induced AEs required treatment discontinuation (patients 3 and 6, Table 3). One grade IV serious adverse event (SAE) with a lethal cervical bleeding occurred after removal of the tracheostomy in patient 5 despite being in complete remission (Tables 2 and 3).
Table 3. Patient History
Patient Entity Age, years Prior treatment ORR in 3/4 months BOR CT+PET PFS, months OS, months Adverse events (CTCAE in grade °) Median dose lenvatinib, mg/day Current therapy/ outcome
1 PDTC 63 S Rx C/T PR PR 25 27 Hypertension °II
Fatigue °II
Anorexia °I
Oral mucositis °I 24 PD/death after stopping lenvatinib due to a knee surgery
2 ATC 76 S Rx C/T PR CR 40 40 Hypertension °II
Anorexia °II 24 Alive, CR after 12 months lenvatinib/pembrolizumab, now without treatment
3 PDTC 49 S RIT C/T PR PR 15 23 Anorexia °III
Abdominal pain °III 14 PD/death, lenvatinib on/off due to weight loss/abdominal pain
4 ATC 68 S Rx C/T PR CR 26 26 Anorexia °I
Loss of appetite °II
Proteinuria °I
Hypertension °II 20 Alive, CR after 10 months of treatment, now pembrolizumab mono
5 ATC 63 S Rx C/T PR CR 11 11 Diarrhea °II
Hypertension °II
Cervical bleeding °IV 20 CR after 7 months of treatment. Death due to cervical bleeding
6 ATC 88 S Rx C/T SD SD 4 7 Diarrhea °II
Anorexia °III
Proteinuria °II
Fatigue °III
Oral mucositis °II 14 PD/death after stopping medication due to side effects
7 ATC 64 S RIT Rx PR CR 19 19 Hypertension °II
Fatigue °II
Joint pain °II
Hand–foot syndrome °I 24 Alive, CR, lenvatinib/pembrolizumab for 12 months, now pembrolizumab mono
8 ATC 60 S R C/T PD PD 1 1 Hypertension °II 24 PD/death due to cervical tumor progression
Patient characteristics including diagnosis, previous therapy (S, RIT, Rx, C/T), patient age, PFS, ORR, BOR, OS, response after 3 months, maximum response, main side effects, median dose lenvatinib in mg/day, dose pembrolizumab, current treatment/outcome. CTCAE grades in roman numbers. Responses were assessed via the RECIST v1.1 radiology assessment and FDG uptake according to the EORTC criteria for PET.
BOR, best overall response; C/T, chemotherapy; CT, computed tomography; CR, complete response; CTCAE, Common Terminology Criteria for Adverse Events; FDG, [18F] fluorodeoxyglucose; ORR, overall response rate; OS, overall survival; PD, progressive disease; PET, positron emission tomography; PFS, progression free survival; PR, partial response; Rx, radiation therapy; S, surgery; SD, stable disease.
After four months of treatment, lenvatinib/pembrolizumab was discontinued due to severe weight loss/anorexia (grade III) in the 88-year-old patient (patient 6), and she died due to disease progression three months later. One patient was intolerant to lenvatinib treatment due to grade III abdominal pain and weight loss/anorexia (patient 3). Lenvatinib was reduced from 24 to 20 to 14 and 12 mg/day in a stepwise manner, and after 14 months, lenvatinib/pembrolizumab treatment was discontinued. Two patients received the full dose of lenvatinib 24 mg for 24 months (Fig. 1C). Pembrolizumab was given for up to 40 months and will be continued in all patients reaching a CR for two more years (Fig. 1D).
Treatment efficacy
Treatment response was first assessed 3–4 months after lenvatinib/pembrolizumab treatment. Six of eight patients had a PR according to the RECIST v1.1 criteria (Fig. 1A). ORR for ATCs was 66% (4/6 PR). The 88-year-old patient (ATC) at 14 mg lenvatinib had SD (patient 6). One ATC patient (patient 8) did not respond to lenvatinib/pembrolizumab treatment combination and died within the first month of treatment due to cervical tumor progression (1/8 progressive disease) (Fig. 1A and Supplementary Data).
BOR changed in four ATC patients from PR to CR within 16 months of treatment (total CR rate 50%, CR rate for ATC 66%) (Fig. 1B). Individual patient history is summarized in the Supplementary Data. ATC patient 2 had a confirmed CR for all target- and nontarget lesions 16 months after lenvatinib/pembrolizumab treatment, and stopped taking lenvatinib after 2 years (24 mg daily for 24 months), but continued pembrolizumab for 16 more months (40 months total). He stopped treatment for 6 months and is still in CR. ATC patient 4 with lung and brain metastases had a PR 12 months after starting treatment, but all lesions in the lung were without FDG uptake (CR according to the EORTC criteria for PET). All lung lesions were surgically removed and showed a pathological CR (no viable tumor cells). Therefore, the patient was judged as having a CR and has discontinued lenvatinib after 1 year of treatment, and continues with pembrolizumab only (26 months total). Patient 7 with a massive neck tumor and lung metastasis had a PET/CT confirmed CR 12 months after starting treatment. He stopped lenvatinib after 15 months and now continues with pembrolizumab only (19 months total). ATC patient 5 had confirmed CR 10 months after treatment start, but unfortunately died due to bleeding complications after removal of the tracheostomy tube (Table 3 and Supplementary Table S2).
Treatment durations ranged from 1 to 40 months (ATC: 40, 26, 19, 18, 4, and 1 month; PDTC: 25 and 15 months, respectively), with three patients being treated for more than 2 years (Fig. 1D). At the time of data cutoff, 3 of 8 patients (patients 2, 4, and 7, all ATCs) were still alive and on therapy (40, 26, and 19 months). We stopped the treatment of patient 2 after 40 months of treatment, and he is now regularly monitored by CT scans every 3 months. The other patients died due to disease progression (2/6 ATC, 2/2 PDTC) or hemorrhage (grade IV SAE, patient 5, Table 3). ATC patient 8 was resistant to the treatment. ATC patients 1 and 6 died shortly after discontinuation of the lenvatinib treatment caused by lenvatinib intolerance in patient 6 (grade III anorexia), and because lenvatinib had to be discontinued due to an infectious complication after a knee surgery in patient 1 (Table 3). The median PFS for the total cohort was 17.6 months, and the median OS was 19 months (Fig. 2). Data analysis for ATC only showed a median PFS of 16.8 months and a median OS of 17.3 months (Fig. 2).
FIG. 2. Kaplan–Meier curves for ATCs only and total patients. (A) PFS in all patients and ATC only. (B) OS in all patients and ATC only. ATC, anaplastic thyroid carcinoma; OS, overall survival; PFS, progression-free survival.
Biomarkers
To assess potential predictors of treatment response, we investigated the PD-L1 expression of the tumor cells and macrophages/immune cells. Furthermore, WES was performed in 7 of 8 patients, and sequences were compared to germ line sequences to assess somatic mutations and the TMB. In 1 patient (1/8), targeted sequencing for 11 frequently mutated genes (Supplementary Table S1) was performed due to low material. All tumors were positive for PD-L1 expression with a TPS ranging from 1% to 90%, and 5 of 8 patients with TPS >50% (Table 4). The CPS ranged from 5 to 100 (Table 4). Interestingly, the ATC patient with the lowest TPS (1%) and CPS 5 did not respond to the treatment (patient 8). In contrast, the patients with responses lasting more than two years and those achieving a CR all had PD-L1 TPS >50% (5/8), a CPS >75 (3/8), or a high mutation frequency above 5 mutations per megabase (3/8). The patient (patient 2) with the highest number of mutations (>1400 somatic mutations) has the longest CR duration (30 months).
Table 4. Biomarker Analysis
Patient ORR after 3/4 months (RECIST 1.1) BOR (CT/MRI/PET-CT) Response according to PET-CT TPS, % CPS Somatic mutations TMB (mutations/Mb)
1 PR PR PR 50 40 106 13.79
2 PR CR CR 60 75 1447 81.87
3 PR PR PR 10 10 79 4.08
4 PR CR CR 90 100 19 3
5 PR CR n.a. 80 100 29 3.3
6 SD SD n.a. 60 65 24 3.58
7 PR CR CR 5 7 138 5.59
8 PD PD n.a. 1 5 n.a. n.a.
CPS, combined proportion score; MRI, magnet resonance tomography; n.a., not applicable; TMB, tumor mutation burden; TPS, tumor proportion score.
Discussion
Current treatment options for ATC are limited, and response rates are low and short-lived, with marginal to absent CR (13,14). Only the small proportion of BRAFV600E-mutated ATC (about 20%) can be effectively treated with a BRAF/MEK inhibitor combination of dabrafenib and trametinib (10,11), but for the other 70–80% of ATCs, no treatment options are approved after chemotherapy failure in most countries.
ATC and PDTC are characterized by a very high proliferation rate and tumor invasiveness, driven by concurrent mutations in several pro-proliferative pathways (RAS, WNT, loss of TP53), and strongly activated VEGF/FGF signaling. PD-L1 and TMB are upregulated, but the response to single immune checkpoint inhibition often comes too late and is overrun by the aggressiveness of the disease (36).
While many kinase inhibitors (sorafenib/pazopanib) failed to show treatment efficacy in ATC (30–32), lenvatinib trials demonstrated some promising effects, with 17.4–43% PRs and up to 50% SD (27–29). CRs were absent and PFS lasted only between 77 days and 7.4 months (27–29). Besides its fast, but short-lived antiproliferative effects, lenvatinib was shown to improve immune responses to immune checkpoint inhibitors in mice. Therefore, by combining both agents, we aimed to use lenvatinib as a fast and effective bridging treatment and immuno-sensitizer for the immune checkpoint inhibitor pembrolizumab in ATC/PDTC patients.
In contrast to single-agent therapy, the combination of lenvatinib and pembrolizumab was highly effective in our treatment cohort. Eight ATC/PDTC patients who had previously been treated with several lines of therapy including chemotherapy, chemoirradiation, and even single immune checkpoint inhibition (1/8) received a combination of lenvatinib and pembrolizumab for a maximum of 40 months. The combination treatment was well tolerated and could be sustained over one year in half of the patients, and even over two years in 37% (3/8) of the patients. Half of the ATC patients (3/6) were still on therapy at data cutoff with no sustained grade III/IV toxicities despite having initially metastatic disease; three patients had confirmed CR by PET/CT and/or histopathologic examination of former metastatic sites. Seventy-five percent of all patients and 66% of the ATC patients reached a PR/CR within 16 months of treatment. The remission rates observed with lenvatinib/pembrolizumab combination in ATC/PDTC are similar to previously published data for other heavily pretreated solid tumors, such as patients with head and neck tumors, endometrial, renal cell, or hepatocellular carcinoma (39–42). As CRs and long-lasting remissions were rarely observed in ATC patients treated with lenvatinib only (27–29), the addition of pembrolizumab is most likely inducing this effect.
In patients who are already resistant to TKI treatment, the addition of pembrolizumab is only partially functional with a PFS of only 2.96 months (43), which indicates that the up-front combination of lenvatinib and pembrolizumab might be much more effective than using these drugs sequentially.
TMB and PD-L1 expression levels (TPS/CPS) are independent biomarkers for response to immune checkpoint inhibitors in solid tumors (30,46,47). In our analysis, patients reaching a CR or those who had long-term remission over two years all had a TPS above 50%, a CPS higher than 75, and/or a TMB >5/MB, indicating that those may be biomarkers for response to lenvatinib/pembrolizumab treatment in ATC/PDTC.
In general, the combination of lenvatinib and pembrolizumab was well tolerated even in the elderly patients with a higher ECOG performance status. Results are encouraging with an ORR of 75%, including a CR rate of 50% (66% in ATCs) and responses over 2 years. Therefore, the treatment results and biomarkers will be further evaluated in a phase II clinical trial with lenvatinib and pembrolizumab in ATC/PDTC patients (ATLEP trial, Anaplastic Thyroid Carcinoma Lenvatinib Pembrolizumab, EudraCT No. 2017-004570-34).
Supplementary Material
Supplemental data
Supplemental data
Supplemental data
Supplemental data
Supplemental data
Acknowledgments
Thanks to our patients and relatives for their support for this study. Thanks to Prof. Roland Mertelsmann for his continuous support and wisdom. Thanks to the molecular tumor board and the CCCF for their support.
Authors' Contributions
C.D., J.S., C.M., O.T., H.W., and N.B. wrote the article. J.R., C.K., and P.T.M. performed and evaluated PET/CTs. K.A., and S.K. performed PD-L1 staining and evaluation. M.R. designed figures. M.B. and P.M. analyzed WES data. A.Z., P.R., M.K., C.W., T.S., C.S., C.M., C.K., N.B., and K.L. treated patients and revised the article.
Author Disclosure Statement
C.D. received honoraria and travel costs for consultancy role at Eisai, AbbVie, and Gilead. M.K. received honoraria and travel costs for consultancy role at Eisai GmbH. A.Z. received honoraria and travel costs for consultancy role at Eisai, J&J, and Merck and participates in the Keynote 158 trial.
Funding Information
Resarch funding grant for IIT trials from the University of Freiburg.
Supplementary Material
Supplementary Data
Supplementary Table S1
Supplementary Table S2
Supplementary Table S3
Supplementary Table S4 | CARBOPLATIN, PACLITAXEL | DrugsGivenReaction | CC BY | 33509020 | 20,559,963 | 2021-07 |
Give an alphabetized list of all active substances of drugs taken by the patient who experienced 'Metastases to kidney'. | Combination of Lenvatinib and Pembrolizumab Is an Effective Treatment Option for Anaplastic and Poorly Differentiated Thyroid Carcinoma.
Anaplastic thyroid carcinoma (ATC) and metastatic poorly differentiated thyroid carcinomas (PDTCs) are rare aggressive malignancies with poor overall survival (OS) despite extensive multimodal therapy. These tumors are highly proliferative, with frequently increased tumor mutational burden (TMB) compared with differentiated thyroid carcinomas, and elevated programmed death ligand 1 (PD-L1) levels. These tumor properties implicate responsiveness to antiangiogenic and antiproliferative multikinase inhibitors such as lenvatinib, and immune checkpoint inhibitors such as pembrolizumab. In a retrospective study, we analyzed six patients with metastatic ATC and two patients with PDTC, who received a combination therapy of lenvatinib and pembrolizumab. Lenvatinib was started at 14-24 mg daily and combined with pembrolizumab at a fixed dose of 200 mg every three weeks. Maximum treatment duration with this combination was 40 months, and 3 of 6 ATC patients are still on therapy. Patient tumors were characterized by whole-exome sequencing and PD-L1 expression levels (tumor proportion score [TPS] 1-90%). Best overall response (BOR) within ATCs was 66% complete remissions (4/6 CR), 16% stable disease (1/6 SD), and 16% progressive disease (1/6 PD). BOR within PDTCs was partial remission (PR 2/2). The median progression-free survival was 17.75 months for all patients, and 16.5 months for ATCs, with treatment durations ranging from 1 to 40 months (1, 4, 11, 15, 19, 25, 27, and 40 months). Grade III/IV toxicities developed in 4 of 8 patients, requiring dose reduction/discontinuation of lenvatinib. The median OS was 18.5 months, with three ATC patients being still alive without relapse (40, 27, and 19 months) despite metastatic disease at the time of treatment initiation (UICC and stage IVC). All patients with long-term (>2 years) or complete responses (CRs) had either increased TMB or a PD-L1 TPS >50%. Our results implicate that the combination of lenvatinib and pembrolizumab might be safe and effective in patients with ATC/PDTC and can result in complete and long-term remissions. The combination treatment is now being systematically examined in a phase II clinical trial (Anaplastic Thyroid Carcinoma Lenvatinib Pembrolizumab [ATLEP]) in ATC/PDTC patients.
Introduction
Anaplastic thyroid carcinoma (ATC) is a rare disease with an extremely high mortality rate and a 10-year survival below 5% (1). ATCs grow very fast, infiltrate into cervical structures, such as the esophagus, trachea, or blood vessels, and metastasize to the lung, brain, and bone. Even with extensive multimodal therapy (surgery, external beam radiotherapy, and chemotherapy), the median overall survival (OS) is only 3–5 months (1–3). ATC frequently arises from differentiated thyroid carcinoma (DTC) but can also emerge de novo. Typical molecular features of ATC are mutations in TP53 (54–64%), TERT (61%), KRAS/NRAS (28–43%), BRAF (18–28%), NF1, NF2, PI3K, PTEN, and genes in the WNT signaling pathway (4–9). BRAF/MEK inhibitor combinations (dabrafenib/trametinib) are approved for BRAFV600E-mutated ATCs and have significantly enhanced survival and has high treatment response (overall response rate [ORR] 69%) (10,11). All other locally advanced or metastatic ATCs (about 75%) are individually treated with carboplatin, paclitaxel, or doxorubicin containing chemotherapeutic regimens with very modest ORR (10–20%) lasting only for a few months (progression-free survival [PFS] 3–4 months) (12–15). Poorly differentiated thyroid carcinoma (PDTC) has a more favorable prognosis, with some patients being partially responsive to radioiodine therapy (RIT), but 10-year survival is also below 10%.
Compared with DTC, ATC/PDTC are characterized by an elevated tumor mutation burden, higher programmed death ligand 1 (PD-L1) levels, and increased neoangiogenesis (VEGFR/FGFR signaling) (7,16–22), suggesting that they may be sensitivity to immune checkpoint and neoangiogenesis inhibitors.
Lenvatinib is an antiangiogenic (VEGFR 1–3/FGFR 1–4) and antiproliferative (RET/PDGFR) tyrosine kinase inhibitor (TKI), which is approved for DTC refractory to radioiodine treatment (23). PFS in DTC is 19.4 months (23–26), but it is reduced to 14.8 months in PDTC, and all patients ultimately develop treatment resistance or treatment intolerance (26). In ATC, the PFS is even shorter (5.6–7.4 months) with variable ORR between 17.4% and 43%, depending on the initial tumor stage (27–29).
Pembrolizumab is an immune checkpoint inhibitor targeting PD-1 on immune cells. Response to pembrolizumab treatment is associated with elevated expression of PD-L1 or high tumor mutational burden (TMB) (30–34). DTC have low TMB and low PD-L1 expression (CPS/TPS) and hence have low response rates to immune checkpoint inhibitor treatments (ORR 9%) (35). In ATC with higher PD-L1/TMB, the effect of immune checkpoint inhibitors is still low (ORR <10%) (36,37), as the slow response to treatment (>8 weeks) cannot keep pace with the aggressive tumor growth.
In vitro studies and mouse experiments indicate synergism between lenvatinib and pembrolizumab (38). Lenvatinib not only blocks tumor neoangiogenesis and proliferation but also enhances immune cell invasion into the tumor and therefore fosters immune responses induced by immune checkpoint inhibitors (38). Furthermore, phase II trials with the lenvatinib/pembrolizumab combination in patients with extensively pretreated metastatic solid tumors (renal, ovarian, and endometrial carcinoma) not only showed acceptable toxicity but also very promising response rates (84% partial response [PR], 16% stable disease [SD]). Phase II/III trials for endometrial, head and neck, and hepatocellular carcinoma validated the high efficacy and safety for this combination (39–42). In ATC, pembrolizumab treatment was used as a salvage strategy after patients had failed lenvatinib or dabrafenib monotherapy or a dabrafenib/trametinib combination therapy. Pembrolizumab was added to the respective TKI and induced PR rates of 43%, but with a very short PFS of only 2.96 months (43).
In contrast to this study, we directly combined lenvatinib and pembrolizumab as front-line therapy after chemotherapy failure in eight patients with metastatic ATC (n = 6) or PDTC (n = 2) and examined treatment outcome and biomarkers for this approach.
Materials and Methods
Study population and patient characteristics
This is a retrospective, single-center (University Medical Center Freiburg) cohort study of eight patients with metastatic ATC (n = 6) or PDTC (n = 2) treated with a combination of the multikinase inhibitor lenvatinib and the immune checkpoint inhibitor pembrolizumab (L/P). Patient data were collected from March 2016 to December 2019 (Table 1). ATC/PDTC diagnosis was histopathologically confirmed by the Institute for Pathology, Freiburg, in all patients. Patients had no BRAFV600E mutation, but numerous other mutations were present (Supplementary Table S1). All patients were pretreated with irradiation, chemotherapy, or RIT (Table 1 and Supplementary Table S2). Adverse events (AEs) were reported according to the National Cancer Institute Common Terminology Criteria for Adverse Events (CTCAE version 5)–GBG (Table 2). The retrospective study was approved by the Institutional Review Board (IRB) of the University Freiburg.
Table 1. Baseline Characteristics
Median age at treatment start (range), years 63.5 (49–88)
Sex, n (%)
Men 4 (50)
Women 4 (50)
Performance status, n (%)
ECOG 0 3 (37.5)
ECOG 1 3 (37.5)
ECOG 2 2 (25)
Pathological diagnosis, n (%)
ATC 6 (75)
PDTC 2 (25)
Location of metastases, n (%)
Lung 8 (100)
Bone 2 (25)
Kidney 1 (12.5)
Brain 1 (12.5)
Liver 1 (12.5)
Skin 1 (12.5)
Cervical relapse, n (%) 6 (75)
Previous therapy, n (%)
Surgery 8 (100)
Radiation ± chemosensitizing 7 (87.5)
Chemotherapy 6 (75)
RIT 2 (25)
ATC, anaplastic thyroid carcinoma; ECOG, Eastern Cooperative Oncology Group; PDTC, poorly differentiated thyroid carcinoma; RIT, radioiodine therapy.
Table 2. Adverse Events According to the Common Terminology Criteria for Adverse Events Version 5.0
Event Grade I/II (%) Grade III/IV (%)
Total 8/8 (100) 3/8 (36)
Hypertension 5/8 (63)
Fatigue 2/8 (25) 1/8 (13)
Anorexia 2/8 (25) 2/8 (25)
Oral mucositis 2/8 (25)
Joint/muscle pain 1/8 (13)
Hand–foot syndrome 1/8 (13)
Diarrhea 1/8 (13)
Proteinuria 1/8 (13)
Abdominal pain 1/8 (13)
Cervical bleeding 1/8 (13)
Data are given as totals and %. Events reported are listed in descending frequency of columns for grade I/II and grade III/IV. A patients with several multiple occurrences of an adverse event is counted only once with the highest grade. A patient with multiple adverse events is counted only once in the total row.
Treatment strategy
Patients started with lenvatinib 24 mg oral daily if the body weight (BW) was more than 80 kg, or 20 mg for BW less than 80 kg. Pembrolizumab infusions were started in between 1 and 4 weeks after initiation of lenvatinib at a fixed dose of 200 mg total every 3 weeks. Dose for lenvatinib was stepwise reduced upon occurrence of side effects according to clinical judgment. Lenvatinib was given at least for 1 year and was then stopped in patients with confirmed complete response (CR). Pembrolizumab was given for up to 40 months. It will be continued in all patients reaching a CR for two more years.
Response assessment
Radiology assessment including cervical, chest, and abdominal computed tomography (CT) scans was performed before treatment and then every 3–4 months. Response to therapy was determined centrally using the RECIST 1.1 criteria (Fig. 1A and Supplementary Table S3). Positron emission tomography (PET)–CT using [18F] fluorodeoxyglucose (FDG) (PET/CT) was performed before treatment, and after 12–16 months of treatment to confirm CRs (the European Organisation for Research and Treatment of Cancer [EORTC] response criteria for PET). In case of persistent lesions without tracer uptake on PET/CT (PR according to the RECIST 1.1 [CT scan], but CR according to the EORTC criteria for PET), lesions were surgically removed (1/8) to confirm the absence of viable tumor tissue (pathological CR criteria, Supplementary Table S4).
FIG. 1. (A) ORR after 3–4 months of treatment, 6/8 PR, 1/8 SD, 1/8 PD. (B) BOR within 16 months of treatment. (C) Lenvatinib dosage and changes over time. (D) Treatment duration and ongoing treatment. Patients in CR. BOR, best overall response; CR, complete response; ORR, overall response rate; PD, progressive disease; PR, partial response; SD, stable disease.
The efficacy of the combination treatment was assessed by ORR 3–4 months after starting treatment, best overall response (BOR) (Fig. 1B), PFS, and OS. PFS was defined as the time elapsed between starting treatment and progression or death, whichever occurred first. OS was defined as the time between starting treatment and death.
Molecular testing and immunohistochemistry
Molecular testing by whole-exome sequencing (WES) was performed from formalin-fixed and paraffin-embedded tissue specimens at the Deutsches Krebsforschungszentrum Heidelberg (DKFZ) as described previously (44,45). PD-L1 status was determined by immunohistochemistry (antibody clone SP263; Ventana) in tumor tissue specimens obtained at initial diagnosis before treatment. The tumor proportion score (TPS) was determined as proportion of PD-L1-positive tumor cells of 100 tumor cells. The combined proportion score (CPS), as amount of PD-L1-positive tumor and immune cells within 100 tumor cells, was also determined centrally at the Department of Pathology of the University Medical Center Freiburg.
Statistical analysis
Kaplan–Meier curves were used for OS and PFS. Descriptive statistics were used to summarize patients' characteristics and AEs. Statistical analysis was performed using IBM SPSS Statistics version 25.
Results
Eight patients with metastatic ATC (n = 6) or PDTC (n = 2) were treated with a combination of lenvatinib and pembrolizumab after failing chemotherapy, irradiation, or RIT (Table 1 and Supplementary Table S2). All the 8 patients had been extensively pretreated with surgery (8/8), local cervical external beam radiation therapy (6/8), RIT (2/2), local cerebral irradiation therapy (1/8), or systemic chemotherapy alone (6/8) (carboplatin/paclitaxel [4/8], cisplatin/paclitaxel [1/8], cisplatin/doxorubicin [1/8], and paclitaxel only [1/8]) (Table 1 and Supplementary Table S2). The median patient age was 66.4 years. At the beginning of treatment with lenvatinib/pembrolizumab, all patients had stage IVC. All patients had lung metastasis (8/8), and 2 of 8 skeletal metastasis, 1 of 8 liver metastasis, 1 of 8 kidney metastasis, 1 of 8 skin metastasis, and 1 of 8 brain metastasis. Six of eight patients also had progression of their local tumor. Eastern Cooperative Oncology Group (ECOG) performance status ranged from 0 to 2, with 3 ECOG 0 (38%), 3 ECOG 1 (38%), and 2 ECOG 2 (25%). Molecular diagnostics showed that none of the patients had a BRAFV600E mutation, but numerous other mutations typical for ATC/PDTC were detected and are listed in Supplementary Table S1.
Treatment regimen and AEs
Lenvatinib was started at a daily dose of 24 mg in 5 of 8 patients (BW more than 80 kg) and 20 mg in 2 patients with bodyweight less than 80 kg. An 88-year-old woman started on 14 mg/day (Fig. 1C and Table 3). Pembrolizumab treatment was initiated after a median of 2.7 weeks (ranging from 1 to 4 weeks after starting lenvatinib) and was given i.v. at a fixed dose of 200 mg every 3 weeks. In general, the therapy was well tolerated with the predominant grade II to IV AEs (AEs according to the CTCAE) being hypertension (5/8), fatigue (4/8), weight loss/anorexia (3/8), oral mucositis (2/8), diarrhea (2/8), joint/muscle pain (1/8), and hand–foot syndrome (1/8) (Table 2). The lenvatinib dose was reduced stepwise upon occurrence of intolerable side effects from 24 to 20, 14, 12, and 10 mg/day (Fig. 1C). Most side effects resolved after reducing the dose of lenvatinib, but in two patients, lenvatinib-induced AEs required treatment discontinuation (patients 3 and 6, Table 3). One grade IV serious adverse event (SAE) with a lethal cervical bleeding occurred after removal of the tracheostomy in patient 5 despite being in complete remission (Tables 2 and 3).
Table 3. Patient History
Patient Entity Age, years Prior treatment ORR in 3/4 months BOR CT+PET PFS, months OS, months Adverse events (CTCAE in grade °) Median dose lenvatinib, mg/day Current therapy/ outcome
1 PDTC 63 S Rx C/T PR PR 25 27 Hypertension °II
Fatigue °II
Anorexia °I
Oral mucositis °I 24 PD/death after stopping lenvatinib due to a knee surgery
2 ATC 76 S Rx C/T PR CR 40 40 Hypertension °II
Anorexia °II 24 Alive, CR after 12 months lenvatinib/pembrolizumab, now without treatment
3 PDTC 49 S RIT C/T PR PR 15 23 Anorexia °III
Abdominal pain °III 14 PD/death, lenvatinib on/off due to weight loss/abdominal pain
4 ATC 68 S Rx C/T PR CR 26 26 Anorexia °I
Loss of appetite °II
Proteinuria °I
Hypertension °II 20 Alive, CR after 10 months of treatment, now pembrolizumab mono
5 ATC 63 S Rx C/T PR CR 11 11 Diarrhea °II
Hypertension °II
Cervical bleeding °IV 20 CR after 7 months of treatment. Death due to cervical bleeding
6 ATC 88 S Rx C/T SD SD 4 7 Diarrhea °II
Anorexia °III
Proteinuria °II
Fatigue °III
Oral mucositis °II 14 PD/death after stopping medication due to side effects
7 ATC 64 S RIT Rx PR CR 19 19 Hypertension °II
Fatigue °II
Joint pain °II
Hand–foot syndrome °I 24 Alive, CR, lenvatinib/pembrolizumab for 12 months, now pembrolizumab mono
8 ATC 60 S R C/T PD PD 1 1 Hypertension °II 24 PD/death due to cervical tumor progression
Patient characteristics including diagnosis, previous therapy (S, RIT, Rx, C/T), patient age, PFS, ORR, BOR, OS, response after 3 months, maximum response, main side effects, median dose lenvatinib in mg/day, dose pembrolizumab, current treatment/outcome. CTCAE grades in roman numbers. Responses were assessed via the RECIST v1.1 radiology assessment and FDG uptake according to the EORTC criteria for PET.
BOR, best overall response; C/T, chemotherapy; CT, computed tomography; CR, complete response; CTCAE, Common Terminology Criteria for Adverse Events; FDG, [18F] fluorodeoxyglucose; ORR, overall response rate; OS, overall survival; PD, progressive disease; PET, positron emission tomography; PFS, progression free survival; PR, partial response; Rx, radiation therapy; S, surgery; SD, stable disease.
After four months of treatment, lenvatinib/pembrolizumab was discontinued due to severe weight loss/anorexia (grade III) in the 88-year-old patient (patient 6), and she died due to disease progression three months later. One patient was intolerant to lenvatinib treatment due to grade III abdominal pain and weight loss/anorexia (patient 3). Lenvatinib was reduced from 24 to 20 to 14 and 12 mg/day in a stepwise manner, and after 14 months, lenvatinib/pembrolizumab treatment was discontinued. Two patients received the full dose of lenvatinib 24 mg for 24 months (Fig. 1C). Pembrolizumab was given for up to 40 months and will be continued in all patients reaching a CR for two more years (Fig. 1D).
Treatment efficacy
Treatment response was first assessed 3–4 months after lenvatinib/pembrolizumab treatment. Six of eight patients had a PR according to the RECIST v1.1 criteria (Fig. 1A). ORR for ATCs was 66% (4/6 PR). The 88-year-old patient (ATC) at 14 mg lenvatinib had SD (patient 6). One ATC patient (patient 8) did not respond to lenvatinib/pembrolizumab treatment combination and died within the first month of treatment due to cervical tumor progression (1/8 progressive disease) (Fig. 1A and Supplementary Data).
BOR changed in four ATC patients from PR to CR within 16 months of treatment (total CR rate 50%, CR rate for ATC 66%) (Fig. 1B). Individual patient history is summarized in the Supplementary Data. ATC patient 2 had a confirmed CR for all target- and nontarget lesions 16 months after lenvatinib/pembrolizumab treatment, and stopped taking lenvatinib after 2 years (24 mg daily for 24 months), but continued pembrolizumab for 16 more months (40 months total). He stopped treatment for 6 months and is still in CR. ATC patient 4 with lung and brain metastases had a PR 12 months after starting treatment, but all lesions in the lung were without FDG uptake (CR according to the EORTC criteria for PET). All lung lesions were surgically removed and showed a pathological CR (no viable tumor cells). Therefore, the patient was judged as having a CR and has discontinued lenvatinib after 1 year of treatment, and continues with pembrolizumab only (26 months total). Patient 7 with a massive neck tumor and lung metastasis had a PET/CT confirmed CR 12 months after starting treatment. He stopped lenvatinib after 15 months and now continues with pembrolizumab only (19 months total). ATC patient 5 had confirmed CR 10 months after treatment start, but unfortunately died due to bleeding complications after removal of the tracheostomy tube (Table 3 and Supplementary Table S2).
Treatment durations ranged from 1 to 40 months (ATC: 40, 26, 19, 18, 4, and 1 month; PDTC: 25 and 15 months, respectively), with three patients being treated for more than 2 years (Fig. 1D). At the time of data cutoff, 3 of 8 patients (patients 2, 4, and 7, all ATCs) were still alive and on therapy (40, 26, and 19 months). We stopped the treatment of patient 2 after 40 months of treatment, and he is now regularly monitored by CT scans every 3 months. The other patients died due to disease progression (2/6 ATC, 2/2 PDTC) or hemorrhage (grade IV SAE, patient 5, Table 3). ATC patient 8 was resistant to the treatment. ATC patients 1 and 6 died shortly after discontinuation of the lenvatinib treatment caused by lenvatinib intolerance in patient 6 (grade III anorexia), and because lenvatinib had to be discontinued due to an infectious complication after a knee surgery in patient 1 (Table 3). The median PFS for the total cohort was 17.6 months, and the median OS was 19 months (Fig. 2). Data analysis for ATC only showed a median PFS of 16.8 months and a median OS of 17.3 months (Fig. 2).
FIG. 2. Kaplan–Meier curves for ATCs only and total patients. (A) PFS in all patients and ATC only. (B) OS in all patients and ATC only. ATC, anaplastic thyroid carcinoma; OS, overall survival; PFS, progression-free survival.
Biomarkers
To assess potential predictors of treatment response, we investigated the PD-L1 expression of the tumor cells and macrophages/immune cells. Furthermore, WES was performed in 7 of 8 patients, and sequences were compared to germ line sequences to assess somatic mutations and the TMB. In 1 patient (1/8), targeted sequencing for 11 frequently mutated genes (Supplementary Table S1) was performed due to low material. All tumors were positive for PD-L1 expression with a TPS ranging from 1% to 90%, and 5 of 8 patients with TPS >50% (Table 4). The CPS ranged from 5 to 100 (Table 4). Interestingly, the ATC patient with the lowest TPS (1%) and CPS 5 did not respond to the treatment (patient 8). In contrast, the patients with responses lasting more than two years and those achieving a CR all had PD-L1 TPS >50% (5/8), a CPS >75 (3/8), or a high mutation frequency above 5 mutations per megabase (3/8). The patient (patient 2) with the highest number of mutations (>1400 somatic mutations) has the longest CR duration (30 months).
Table 4. Biomarker Analysis
Patient ORR after 3/4 months (RECIST 1.1) BOR (CT/MRI/PET-CT) Response according to PET-CT TPS, % CPS Somatic mutations TMB (mutations/Mb)
1 PR PR PR 50 40 106 13.79
2 PR CR CR 60 75 1447 81.87
3 PR PR PR 10 10 79 4.08
4 PR CR CR 90 100 19 3
5 PR CR n.a. 80 100 29 3.3
6 SD SD n.a. 60 65 24 3.58
7 PR CR CR 5 7 138 5.59
8 PD PD n.a. 1 5 n.a. n.a.
CPS, combined proportion score; MRI, magnet resonance tomography; n.a., not applicable; TMB, tumor mutation burden; TPS, tumor proportion score.
Discussion
Current treatment options for ATC are limited, and response rates are low and short-lived, with marginal to absent CR (13,14). Only the small proportion of BRAFV600E-mutated ATC (about 20%) can be effectively treated with a BRAF/MEK inhibitor combination of dabrafenib and trametinib (10,11), but for the other 70–80% of ATCs, no treatment options are approved after chemotherapy failure in most countries.
ATC and PDTC are characterized by a very high proliferation rate and tumor invasiveness, driven by concurrent mutations in several pro-proliferative pathways (RAS, WNT, loss of TP53), and strongly activated VEGF/FGF signaling. PD-L1 and TMB are upregulated, but the response to single immune checkpoint inhibition often comes too late and is overrun by the aggressiveness of the disease (36).
While many kinase inhibitors (sorafenib/pazopanib) failed to show treatment efficacy in ATC (30–32), lenvatinib trials demonstrated some promising effects, with 17.4–43% PRs and up to 50% SD (27–29). CRs were absent and PFS lasted only between 77 days and 7.4 months (27–29). Besides its fast, but short-lived antiproliferative effects, lenvatinib was shown to improve immune responses to immune checkpoint inhibitors in mice. Therefore, by combining both agents, we aimed to use lenvatinib as a fast and effective bridging treatment and immuno-sensitizer for the immune checkpoint inhibitor pembrolizumab in ATC/PDTC patients.
In contrast to single-agent therapy, the combination of lenvatinib and pembrolizumab was highly effective in our treatment cohort. Eight ATC/PDTC patients who had previously been treated with several lines of therapy including chemotherapy, chemoirradiation, and even single immune checkpoint inhibition (1/8) received a combination of lenvatinib and pembrolizumab for a maximum of 40 months. The combination treatment was well tolerated and could be sustained over one year in half of the patients, and even over two years in 37% (3/8) of the patients. Half of the ATC patients (3/6) were still on therapy at data cutoff with no sustained grade III/IV toxicities despite having initially metastatic disease; three patients had confirmed CR by PET/CT and/or histopathologic examination of former metastatic sites. Seventy-five percent of all patients and 66% of the ATC patients reached a PR/CR within 16 months of treatment. The remission rates observed with lenvatinib/pembrolizumab combination in ATC/PDTC are similar to previously published data for other heavily pretreated solid tumors, such as patients with head and neck tumors, endometrial, renal cell, or hepatocellular carcinoma (39–42). As CRs and long-lasting remissions were rarely observed in ATC patients treated with lenvatinib only (27–29), the addition of pembrolizumab is most likely inducing this effect.
In patients who are already resistant to TKI treatment, the addition of pembrolizumab is only partially functional with a PFS of only 2.96 months (43), which indicates that the up-front combination of lenvatinib and pembrolizumab might be much more effective than using these drugs sequentially.
TMB and PD-L1 expression levels (TPS/CPS) are independent biomarkers for response to immune checkpoint inhibitors in solid tumors (30,46,47). In our analysis, patients reaching a CR or those who had long-term remission over two years all had a TPS above 50%, a CPS higher than 75, and/or a TMB >5/MB, indicating that those may be biomarkers for response to lenvatinib/pembrolizumab treatment in ATC/PDTC.
In general, the combination of lenvatinib and pembrolizumab was well tolerated even in the elderly patients with a higher ECOG performance status. Results are encouraging with an ORR of 75%, including a CR rate of 50% (66% in ATCs) and responses over 2 years. Therefore, the treatment results and biomarkers will be further evaluated in a phase II clinical trial with lenvatinib and pembrolizumab in ATC/PDTC patients (ATLEP trial, Anaplastic Thyroid Carcinoma Lenvatinib Pembrolizumab, EudraCT No. 2017-004570-34).
Supplementary Material
Supplemental data
Supplemental data
Supplemental data
Supplemental data
Supplemental data
Acknowledgments
Thanks to our patients and relatives for their support for this study. Thanks to Prof. Roland Mertelsmann for his continuous support and wisdom. Thanks to the molecular tumor board and the CCCF for their support.
Authors' Contributions
C.D., J.S., C.M., O.T., H.W., and N.B. wrote the article. J.R., C.K., and P.T.M. performed and evaluated PET/CTs. K.A., and S.K. performed PD-L1 staining and evaluation. M.R. designed figures. M.B. and P.M. analyzed WES data. A.Z., P.R., M.K., C.W., T.S., C.S., C.M., C.K., N.B., and K.L. treated patients and revised the article.
Author Disclosure Statement
C.D. received honoraria and travel costs for consultancy role at Eisai, AbbVie, and Gilead. M.K. received honoraria and travel costs for consultancy role at Eisai GmbH. A.Z. received honoraria and travel costs for consultancy role at Eisai, J&J, and Merck and participates in the Keynote 158 trial.
Funding Information
Resarch funding grant for IIT trials from the University of Freiburg.
Supplementary Material
Supplementary Data
Supplementary Table S1
Supplementary Table S2
Supplementary Table S3
Supplementary Table S4 | CARBOPLATIN, PACLITAXEL | DrugsGivenReaction | CC BY | 33509020 | 20,559,976 | 2021-07 |
Give an alphabetized list of all active substances of drugs taken by the patient who experienced 'Metastases to lung'. | Combination of Lenvatinib and Pembrolizumab Is an Effective Treatment Option for Anaplastic and Poorly Differentiated Thyroid Carcinoma.
Anaplastic thyroid carcinoma (ATC) and metastatic poorly differentiated thyroid carcinomas (PDTCs) are rare aggressive malignancies with poor overall survival (OS) despite extensive multimodal therapy. These tumors are highly proliferative, with frequently increased tumor mutational burden (TMB) compared with differentiated thyroid carcinomas, and elevated programmed death ligand 1 (PD-L1) levels. These tumor properties implicate responsiveness to antiangiogenic and antiproliferative multikinase inhibitors such as lenvatinib, and immune checkpoint inhibitors such as pembrolizumab. In a retrospective study, we analyzed six patients with metastatic ATC and two patients with PDTC, who received a combination therapy of lenvatinib and pembrolizumab. Lenvatinib was started at 14-24 mg daily and combined with pembrolizumab at a fixed dose of 200 mg every three weeks. Maximum treatment duration with this combination was 40 months, and 3 of 6 ATC patients are still on therapy. Patient tumors were characterized by whole-exome sequencing and PD-L1 expression levels (tumor proportion score [TPS] 1-90%). Best overall response (BOR) within ATCs was 66% complete remissions (4/6 CR), 16% stable disease (1/6 SD), and 16% progressive disease (1/6 PD). BOR within PDTCs was partial remission (PR 2/2). The median progression-free survival was 17.75 months for all patients, and 16.5 months for ATCs, with treatment durations ranging from 1 to 40 months (1, 4, 11, 15, 19, 25, 27, and 40 months). Grade III/IV toxicities developed in 4 of 8 patients, requiring dose reduction/discontinuation of lenvatinib. The median OS was 18.5 months, with three ATC patients being still alive without relapse (40, 27, and 19 months) despite metastatic disease at the time of treatment initiation (UICC and stage IVC). All patients with long-term (>2 years) or complete responses (CRs) had either increased TMB or a PD-L1 TPS >50%. Our results implicate that the combination of lenvatinib and pembrolizumab might be safe and effective in patients with ATC/PDTC and can result in complete and long-term remissions. The combination treatment is now being systematically examined in a phase II clinical trial (Anaplastic Thyroid Carcinoma Lenvatinib Pembrolizumab [ATLEP]) in ATC/PDTC patients.
Introduction
Anaplastic thyroid carcinoma (ATC) is a rare disease with an extremely high mortality rate and a 10-year survival below 5% (1). ATCs grow very fast, infiltrate into cervical structures, such as the esophagus, trachea, or blood vessels, and metastasize to the lung, brain, and bone. Even with extensive multimodal therapy (surgery, external beam radiotherapy, and chemotherapy), the median overall survival (OS) is only 3–5 months (1–3). ATC frequently arises from differentiated thyroid carcinoma (DTC) but can also emerge de novo. Typical molecular features of ATC are mutations in TP53 (54–64%), TERT (61%), KRAS/NRAS (28–43%), BRAF (18–28%), NF1, NF2, PI3K, PTEN, and genes in the WNT signaling pathway (4–9). BRAF/MEK inhibitor combinations (dabrafenib/trametinib) are approved for BRAFV600E-mutated ATCs and have significantly enhanced survival and has high treatment response (overall response rate [ORR] 69%) (10,11). All other locally advanced or metastatic ATCs (about 75%) are individually treated with carboplatin, paclitaxel, or doxorubicin containing chemotherapeutic regimens with very modest ORR (10–20%) lasting only for a few months (progression-free survival [PFS] 3–4 months) (12–15). Poorly differentiated thyroid carcinoma (PDTC) has a more favorable prognosis, with some patients being partially responsive to radioiodine therapy (RIT), but 10-year survival is also below 10%.
Compared with DTC, ATC/PDTC are characterized by an elevated tumor mutation burden, higher programmed death ligand 1 (PD-L1) levels, and increased neoangiogenesis (VEGFR/FGFR signaling) (7,16–22), suggesting that they may be sensitivity to immune checkpoint and neoangiogenesis inhibitors.
Lenvatinib is an antiangiogenic (VEGFR 1–3/FGFR 1–4) and antiproliferative (RET/PDGFR) tyrosine kinase inhibitor (TKI), which is approved for DTC refractory to radioiodine treatment (23). PFS in DTC is 19.4 months (23–26), but it is reduced to 14.8 months in PDTC, and all patients ultimately develop treatment resistance or treatment intolerance (26). In ATC, the PFS is even shorter (5.6–7.4 months) with variable ORR between 17.4% and 43%, depending on the initial tumor stage (27–29).
Pembrolizumab is an immune checkpoint inhibitor targeting PD-1 on immune cells. Response to pembrolizumab treatment is associated with elevated expression of PD-L1 or high tumor mutational burden (TMB) (30–34). DTC have low TMB and low PD-L1 expression (CPS/TPS) and hence have low response rates to immune checkpoint inhibitor treatments (ORR 9%) (35). In ATC with higher PD-L1/TMB, the effect of immune checkpoint inhibitors is still low (ORR <10%) (36,37), as the slow response to treatment (>8 weeks) cannot keep pace with the aggressive tumor growth.
In vitro studies and mouse experiments indicate synergism between lenvatinib and pembrolizumab (38). Lenvatinib not only blocks tumor neoangiogenesis and proliferation but also enhances immune cell invasion into the tumor and therefore fosters immune responses induced by immune checkpoint inhibitors (38). Furthermore, phase II trials with the lenvatinib/pembrolizumab combination in patients with extensively pretreated metastatic solid tumors (renal, ovarian, and endometrial carcinoma) not only showed acceptable toxicity but also very promising response rates (84% partial response [PR], 16% stable disease [SD]). Phase II/III trials for endometrial, head and neck, and hepatocellular carcinoma validated the high efficacy and safety for this combination (39–42). In ATC, pembrolizumab treatment was used as a salvage strategy after patients had failed lenvatinib or dabrafenib monotherapy or a dabrafenib/trametinib combination therapy. Pembrolizumab was added to the respective TKI and induced PR rates of 43%, but with a very short PFS of only 2.96 months (43).
In contrast to this study, we directly combined lenvatinib and pembrolizumab as front-line therapy after chemotherapy failure in eight patients with metastatic ATC (n = 6) or PDTC (n = 2) and examined treatment outcome and biomarkers for this approach.
Materials and Methods
Study population and patient characteristics
This is a retrospective, single-center (University Medical Center Freiburg) cohort study of eight patients with metastatic ATC (n = 6) or PDTC (n = 2) treated with a combination of the multikinase inhibitor lenvatinib and the immune checkpoint inhibitor pembrolizumab (L/P). Patient data were collected from March 2016 to December 2019 (Table 1). ATC/PDTC diagnosis was histopathologically confirmed by the Institute for Pathology, Freiburg, in all patients. Patients had no BRAFV600E mutation, but numerous other mutations were present (Supplementary Table S1). All patients were pretreated with irradiation, chemotherapy, or RIT (Table 1 and Supplementary Table S2). Adverse events (AEs) were reported according to the National Cancer Institute Common Terminology Criteria for Adverse Events (CTCAE version 5)–GBG (Table 2). The retrospective study was approved by the Institutional Review Board (IRB) of the University Freiburg.
Table 1. Baseline Characteristics
Median age at treatment start (range), years 63.5 (49–88)
Sex, n (%)
Men 4 (50)
Women 4 (50)
Performance status, n (%)
ECOG 0 3 (37.5)
ECOG 1 3 (37.5)
ECOG 2 2 (25)
Pathological diagnosis, n (%)
ATC 6 (75)
PDTC 2 (25)
Location of metastases, n (%)
Lung 8 (100)
Bone 2 (25)
Kidney 1 (12.5)
Brain 1 (12.5)
Liver 1 (12.5)
Skin 1 (12.5)
Cervical relapse, n (%) 6 (75)
Previous therapy, n (%)
Surgery 8 (100)
Radiation ± chemosensitizing 7 (87.5)
Chemotherapy 6 (75)
RIT 2 (25)
ATC, anaplastic thyroid carcinoma; ECOG, Eastern Cooperative Oncology Group; PDTC, poorly differentiated thyroid carcinoma; RIT, radioiodine therapy.
Table 2. Adverse Events According to the Common Terminology Criteria for Adverse Events Version 5.0
Event Grade I/II (%) Grade III/IV (%)
Total 8/8 (100) 3/8 (36)
Hypertension 5/8 (63)
Fatigue 2/8 (25) 1/8 (13)
Anorexia 2/8 (25) 2/8 (25)
Oral mucositis 2/8 (25)
Joint/muscle pain 1/8 (13)
Hand–foot syndrome 1/8 (13)
Diarrhea 1/8 (13)
Proteinuria 1/8 (13)
Abdominal pain 1/8 (13)
Cervical bleeding 1/8 (13)
Data are given as totals and %. Events reported are listed in descending frequency of columns for grade I/II and grade III/IV. A patients with several multiple occurrences of an adverse event is counted only once with the highest grade. A patient with multiple adverse events is counted only once in the total row.
Treatment strategy
Patients started with lenvatinib 24 mg oral daily if the body weight (BW) was more than 80 kg, or 20 mg for BW less than 80 kg. Pembrolizumab infusions were started in between 1 and 4 weeks after initiation of lenvatinib at a fixed dose of 200 mg total every 3 weeks. Dose for lenvatinib was stepwise reduced upon occurrence of side effects according to clinical judgment. Lenvatinib was given at least for 1 year and was then stopped in patients with confirmed complete response (CR). Pembrolizumab was given for up to 40 months. It will be continued in all patients reaching a CR for two more years.
Response assessment
Radiology assessment including cervical, chest, and abdominal computed tomography (CT) scans was performed before treatment and then every 3–4 months. Response to therapy was determined centrally using the RECIST 1.1 criteria (Fig. 1A and Supplementary Table S3). Positron emission tomography (PET)–CT using [18F] fluorodeoxyglucose (FDG) (PET/CT) was performed before treatment, and after 12–16 months of treatment to confirm CRs (the European Organisation for Research and Treatment of Cancer [EORTC] response criteria for PET). In case of persistent lesions without tracer uptake on PET/CT (PR according to the RECIST 1.1 [CT scan], but CR according to the EORTC criteria for PET), lesions were surgically removed (1/8) to confirm the absence of viable tumor tissue (pathological CR criteria, Supplementary Table S4).
FIG. 1. (A) ORR after 3–4 months of treatment, 6/8 PR, 1/8 SD, 1/8 PD. (B) BOR within 16 months of treatment. (C) Lenvatinib dosage and changes over time. (D) Treatment duration and ongoing treatment. Patients in CR. BOR, best overall response; CR, complete response; ORR, overall response rate; PD, progressive disease; PR, partial response; SD, stable disease.
The efficacy of the combination treatment was assessed by ORR 3–4 months after starting treatment, best overall response (BOR) (Fig. 1B), PFS, and OS. PFS was defined as the time elapsed between starting treatment and progression or death, whichever occurred first. OS was defined as the time between starting treatment and death.
Molecular testing and immunohistochemistry
Molecular testing by whole-exome sequencing (WES) was performed from formalin-fixed and paraffin-embedded tissue specimens at the Deutsches Krebsforschungszentrum Heidelberg (DKFZ) as described previously (44,45). PD-L1 status was determined by immunohistochemistry (antibody clone SP263; Ventana) in tumor tissue specimens obtained at initial diagnosis before treatment. The tumor proportion score (TPS) was determined as proportion of PD-L1-positive tumor cells of 100 tumor cells. The combined proportion score (CPS), as amount of PD-L1-positive tumor and immune cells within 100 tumor cells, was also determined centrally at the Department of Pathology of the University Medical Center Freiburg.
Statistical analysis
Kaplan–Meier curves were used for OS and PFS. Descriptive statistics were used to summarize patients' characteristics and AEs. Statistical analysis was performed using IBM SPSS Statistics version 25.
Results
Eight patients with metastatic ATC (n = 6) or PDTC (n = 2) were treated with a combination of lenvatinib and pembrolizumab after failing chemotherapy, irradiation, or RIT (Table 1 and Supplementary Table S2). All the 8 patients had been extensively pretreated with surgery (8/8), local cervical external beam radiation therapy (6/8), RIT (2/2), local cerebral irradiation therapy (1/8), or systemic chemotherapy alone (6/8) (carboplatin/paclitaxel [4/8], cisplatin/paclitaxel [1/8], cisplatin/doxorubicin [1/8], and paclitaxel only [1/8]) (Table 1 and Supplementary Table S2). The median patient age was 66.4 years. At the beginning of treatment with lenvatinib/pembrolizumab, all patients had stage IVC. All patients had lung metastasis (8/8), and 2 of 8 skeletal metastasis, 1 of 8 liver metastasis, 1 of 8 kidney metastasis, 1 of 8 skin metastasis, and 1 of 8 brain metastasis. Six of eight patients also had progression of their local tumor. Eastern Cooperative Oncology Group (ECOG) performance status ranged from 0 to 2, with 3 ECOG 0 (38%), 3 ECOG 1 (38%), and 2 ECOG 2 (25%). Molecular diagnostics showed that none of the patients had a BRAFV600E mutation, but numerous other mutations typical for ATC/PDTC were detected and are listed in Supplementary Table S1.
Treatment regimen and AEs
Lenvatinib was started at a daily dose of 24 mg in 5 of 8 patients (BW more than 80 kg) and 20 mg in 2 patients with bodyweight less than 80 kg. An 88-year-old woman started on 14 mg/day (Fig. 1C and Table 3). Pembrolizumab treatment was initiated after a median of 2.7 weeks (ranging from 1 to 4 weeks after starting lenvatinib) and was given i.v. at a fixed dose of 200 mg every 3 weeks. In general, the therapy was well tolerated with the predominant grade II to IV AEs (AEs according to the CTCAE) being hypertension (5/8), fatigue (4/8), weight loss/anorexia (3/8), oral mucositis (2/8), diarrhea (2/8), joint/muscle pain (1/8), and hand–foot syndrome (1/8) (Table 2). The lenvatinib dose was reduced stepwise upon occurrence of intolerable side effects from 24 to 20, 14, 12, and 10 mg/day (Fig. 1C). Most side effects resolved after reducing the dose of lenvatinib, but in two patients, lenvatinib-induced AEs required treatment discontinuation (patients 3 and 6, Table 3). One grade IV serious adverse event (SAE) with a lethal cervical bleeding occurred after removal of the tracheostomy in patient 5 despite being in complete remission (Tables 2 and 3).
Table 3. Patient History
Patient Entity Age, years Prior treatment ORR in 3/4 months BOR CT+PET PFS, months OS, months Adverse events (CTCAE in grade °) Median dose lenvatinib, mg/day Current therapy/ outcome
1 PDTC 63 S Rx C/T PR PR 25 27 Hypertension °II
Fatigue °II
Anorexia °I
Oral mucositis °I 24 PD/death after stopping lenvatinib due to a knee surgery
2 ATC 76 S Rx C/T PR CR 40 40 Hypertension °II
Anorexia °II 24 Alive, CR after 12 months lenvatinib/pembrolizumab, now without treatment
3 PDTC 49 S RIT C/T PR PR 15 23 Anorexia °III
Abdominal pain °III 14 PD/death, lenvatinib on/off due to weight loss/abdominal pain
4 ATC 68 S Rx C/T PR CR 26 26 Anorexia °I
Loss of appetite °II
Proteinuria °I
Hypertension °II 20 Alive, CR after 10 months of treatment, now pembrolizumab mono
5 ATC 63 S Rx C/T PR CR 11 11 Diarrhea °II
Hypertension °II
Cervical bleeding °IV 20 CR after 7 months of treatment. Death due to cervical bleeding
6 ATC 88 S Rx C/T SD SD 4 7 Diarrhea °II
Anorexia °III
Proteinuria °II
Fatigue °III
Oral mucositis °II 14 PD/death after stopping medication due to side effects
7 ATC 64 S RIT Rx PR CR 19 19 Hypertension °II
Fatigue °II
Joint pain °II
Hand–foot syndrome °I 24 Alive, CR, lenvatinib/pembrolizumab for 12 months, now pembrolizumab mono
8 ATC 60 S R C/T PD PD 1 1 Hypertension °II 24 PD/death due to cervical tumor progression
Patient characteristics including diagnosis, previous therapy (S, RIT, Rx, C/T), patient age, PFS, ORR, BOR, OS, response after 3 months, maximum response, main side effects, median dose lenvatinib in mg/day, dose pembrolizumab, current treatment/outcome. CTCAE grades in roman numbers. Responses were assessed via the RECIST v1.1 radiology assessment and FDG uptake according to the EORTC criteria for PET.
BOR, best overall response; C/T, chemotherapy; CT, computed tomography; CR, complete response; CTCAE, Common Terminology Criteria for Adverse Events; FDG, [18F] fluorodeoxyglucose; ORR, overall response rate; OS, overall survival; PD, progressive disease; PET, positron emission tomography; PFS, progression free survival; PR, partial response; Rx, radiation therapy; S, surgery; SD, stable disease.
After four months of treatment, lenvatinib/pembrolizumab was discontinued due to severe weight loss/anorexia (grade III) in the 88-year-old patient (patient 6), and she died due to disease progression three months later. One patient was intolerant to lenvatinib treatment due to grade III abdominal pain and weight loss/anorexia (patient 3). Lenvatinib was reduced from 24 to 20 to 14 and 12 mg/day in a stepwise manner, and after 14 months, lenvatinib/pembrolizumab treatment was discontinued. Two patients received the full dose of lenvatinib 24 mg for 24 months (Fig. 1C). Pembrolizumab was given for up to 40 months and will be continued in all patients reaching a CR for two more years (Fig. 1D).
Treatment efficacy
Treatment response was first assessed 3–4 months after lenvatinib/pembrolizumab treatment. Six of eight patients had a PR according to the RECIST v1.1 criteria (Fig. 1A). ORR for ATCs was 66% (4/6 PR). The 88-year-old patient (ATC) at 14 mg lenvatinib had SD (patient 6). One ATC patient (patient 8) did not respond to lenvatinib/pembrolizumab treatment combination and died within the first month of treatment due to cervical tumor progression (1/8 progressive disease) (Fig. 1A and Supplementary Data).
BOR changed in four ATC patients from PR to CR within 16 months of treatment (total CR rate 50%, CR rate for ATC 66%) (Fig. 1B). Individual patient history is summarized in the Supplementary Data. ATC patient 2 had a confirmed CR for all target- and nontarget lesions 16 months after lenvatinib/pembrolizumab treatment, and stopped taking lenvatinib after 2 years (24 mg daily for 24 months), but continued pembrolizumab for 16 more months (40 months total). He stopped treatment for 6 months and is still in CR. ATC patient 4 with lung and brain metastases had a PR 12 months after starting treatment, but all lesions in the lung were without FDG uptake (CR according to the EORTC criteria for PET). All lung lesions were surgically removed and showed a pathological CR (no viable tumor cells). Therefore, the patient was judged as having a CR and has discontinued lenvatinib after 1 year of treatment, and continues with pembrolizumab only (26 months total). Patient 7 with a massive neck tumor and lung metastasis had a PET/CT confirmed CR 12 months after starting treatment. He stopped lenvatinib after 15 months and now continues with pembrolizumab only (19 months total). ATC patient 5 had confirmed CR 10 months after treatment start, but unfortunately died due to bleeding complications after removal of the tracheostomy tube (Table 3 and Supplementary Table S2).
Treatment durations ranged from 1 to 40 months (ATC: 40, 26, 19, 18, 4, and 1 month; PDTC: 25 and 15 months, respectively), with three patients being treated for more than 2 years (Fig. 1D). At the time of data cutoff, 3 of 8 patients (patients 2, 4, and 7, all ATCs) were still alive and on therapy (40, 26, and 19 months). We stopped the treatment of patient 2 after 40 months of treatment, and he is now regularly monitored by CT scans every 3 months. The other patients died due to disease progression (2/6 ATC, 2/2 PDTC) or hemorrhage (grade IV SAE, patient 5, Table 3). ATC patient 8 was resistant to the treatment. ATC patients 1 and 6 died shortly after discontinuation of the lenvatinib treatment caused by lenvatinib intolerance in patient 6 (grade III anorexia), and because lenvatinib had to be discontinued due to an infectious complication after a knee surgery in patient 1 (Table 3). The median PFS for the total cohort was 17.6 months, and the median OS was 19 months (Fig. 2). Data analysis for ATC only showed a median PFS of 16.8 months and a median OS of 17.3 months (Fig. 2).
FIG. 2. Kaplan–Meier curves for ATCs only and total patients. (A) PFS in all patients and ATC only. (B) OS in all patients and ATC only. ATC, anaplastic thyroid carcinoma; OS, overall survival; PFS, progression-free survival.
Biomarkers
To assess potential predictors of treatment response, we investigated the PD-L1 expression of the tumor cells and macrophages/immune cells. Furthermore, WES was performed in 7 of 8 patients, and sequences were compared to germ line sequences to assess somatic mutations and the TMB. In 1 patient (1/8), targeted sequencing for 11 frequently mutated genes (Supplementary Table S1) was performed due to low material. All tumors were positive for PD-L1 expression with a TPS ranging from 1% to 90%, and 5 of 8 patients with TPS >50% (Table 4). The CPS ranged from 5 to 100 (Table 4). Interestingly, the ATC patient with the lowest TPS (1%) and CPS 5 did not respond to the treatment (patient 8). In contrast, the patients with responses lasting more than two years and those achieving a CR all had PD-L1 TPS >50% (5/8), a CPS >75 (3/8), or a high mutation frequency above 5 mutations per megabase (3/8). The patient (patient 2) with the highest number of mutations (>1400 somatic mutations) has the longest CR duration (30 months).
Table 4. Biomarker Analysis
Patient ORR after 3/4 months (RECIST 1.1) BOR (CT/MRI/PET-CT) Response according to PET-CT TPS, % CPS Somatic mutations TMB (mutations/Mb)
1 PR PR PR 50 40 106 13.79
2 PR CR CR 60 75 1447 81.87
3 PR PR PR 10 10 79 4.08
4 PR CR CR 90 100 19 3
5 PR CR n.a. 80 100 29 3.3
6 SD SD n.a. 60 65 24 3.58
7 PR CR CR 5 7 138 5.59
8 PD PD n.a. 1 5 n.a. n.a.
CPS, combined proportion score; MRI, magnet resonance tomography; n.a., not applicable; TMB, tumor mutation burden; TPS, tumor proportion score.
Discussion
Current treatment options for ATC are limited, and response rates are low and short-lived, with marginal to absent CR (13,14). Only the small proportion of BRAFV600E-mutated ATC (about 20%) can be effectively treated with a BRAF/MEK inhibitor combination of dabrafenib and trametinib (10,11), but for the other 70–80% of ATCs, no treatment options are approved after chemotherapy failure in most countries.
ATC and PDTC are characterized by a very high proliferation rate and tumor invasiveness, driven by concurrent mutations in several pro-proliferative pathways (RAS, WNT, loss of TP53), and strongly activated VEGF/FGF signaling. PD-L1 and TMB are upregulated, but the response to single immune checkpoint inhibition often comes too late and is overrun by the aggressiveness of the disease (36).
While many kinase inhibitors (sorafenib/pazopanib) failed to show treatment efficacy in ATC (30–32), lenvatinib trials demonstrated some promising effects, with 17.4–43% PRs and up to 50% SD (27–29). CRs were absent and PFS lasted only between 77 days and 7.4 months (27–29). Besides its fast, but short-lived antiproliferative effects, lenvatinib was shown to improve immune responses to immune checkpoint inhibitors in mice. Therefore, by combining both agents, we aimed to use lenvatinib as a fast and effective bridging treatment and immuno-sensitizer for the immune checkpoint inhibitor pembrolizumab in ATC/PDTC patients.
In contrast to single-agent therapy, the combination of lenvatinib and pembrolizumab was highly effective in our treatment cohort. Eight ATC/PDTC patients who had previously been treated with several lines of therapy including chemotherapy, chemoirradiation, and even single immune checkpoint inhibition (1/8) received a combination of lenvatinib and pembrolizumab for a maximum of 40 months. The combination treatment was well tolerated and could be sustained over one year in half of the patients, and even over two years in 37% (3/8) of the patients. Half of the ATC patients (3/6) were still on therapy at data cutoff with no sustained grade III/IV toxicities despite having initially metastatic disease; three patients had confirmed CR by PET/CT and/or histopathologic examination of former metastatic sites. Seventy-five percent of all patients and 66% of the ATC patients reached a PR/CR within 16 months of treatment. The remission rates observed with lenvatinib/pembrolizumab combination in ATC/PDTC are similar to previously published data for other heavily pretreated solid tumors, such as patients with head and neck tumors, endometrial, renal cell, or hepatocellular carcinoma (39–42). As CRs and long-lasting remissions were rarely observed in ATC patients treated with lenvatinib only (27–29), the addition of pembrolizumab is most likely inducing this effect.
In patients who are already resistant to TKI treatment, the addition of pembrolizumab is only partially functional with a PFS of only 2.96 months (43), which indicates that the up-front combination of lenvatinib and pembrolizumab might be much more effective than using these drugs sequentially.
TMB and PD-L1 expression levels (TPS/CPS) are independent biomarkers for response to immune checkpoint inhibitors in solid tumors (30,46,47). In our analysis, patients reaching a CR or those who had long-term remission over two years all had a TPS above 50%, a CPS higher than 75, and/or a TMB >5/MB, indicating that those may be biomarkers for response to lenvatinib/pembrolizumab treatment in ATC/PDTC.
In general, the combination of lenvatinib and pembrolizumab was well tolerated even in the elderly patients with a higher ECOG performance status. Results are encouraging with an ORR of 75%, including a CR rate of 50% (66% in ATCs) and responses over 2 years. Therefore, the treatment results and biomarkers will be further evaluated in a phase II clinical trial with lenvatinib and pembrolizumab in ATC/PDTC patients (ATLEP trial, Anaplastic Thyroid Carcinoma Lenvatinib Pembrolizumab, EudraCT No. 2017-004570-34).
Supplementary Material
Supplemental data
Supplemental data
Supplemental data
Supplemental data
Supplemental data
Acknowledgments
Thanks to our patients and relatives for their support for this study. Thanks to Prof. Roland Mertelsmann for his continuous support and wisdom. Thanks to the molecular tumor board and the CCCF for their support.
Authors' Contributions
C.D., J.S., C.M., O.T., H.W., and N.B. wrote the article. J.R., C.K., and P.T.M. performed and evaluated PET/CTs. K.A., and S.K. performed PD-L1 staining and evaluation. M.R. designed figures. M.B. and P.M. analyzed WES data. A.Z., P.R., M.K., C.W., T.S., C.S., C.M., C.K., N.B., and K.L. treated patients and revised the article.
Author Disclosure Statement
C.D. received honoraria and travel costs for consultancy role at Eisai, AbbVie, and Gilead. M.K. received honoraria and travel costs for consultancy role at Eisai GmbH. A.Z. received honoraria and travel costs for consultancy role at Eisai, J&J, and Merck and participates in the Keynote 158 trial.
Funding Information
Resarch funding grant for IIT trials from the University of Freiburg.
Supplementary Material
Supplementary Data
Supplementary Table S1
Supplementary Table S2
Supplementary Table S3
Supplementary Table S4 | CARBOPLATIN, PACLITAXEL | DrugsGivenReaction | CC BY | 33509020 | 20,543,320 | 2021-07 |
Give an alphabetized list of all active substances of drugs taken by the patient who experienced 'Metastases to lymph nodes'. | Combination of Lenvatinib and Pembrolizumab Is an Effective Treatment Option for Anaplastic and Poorly Differentiated Thyroid Carcinoma.
Anaplastic thyroid carcinoma (ATC) and metastatic poorly differentiated thyroid carcinomas (PDTCs) are rare aggressive malignancies with poor overall survival (OS) despite extensive multimodal therapy. These tumors are highly proliferative, with frequently increased tumor mutational burden (TMB) compared with differentiated thyroid carcinomas, and elevated programmed death ligand 1 (PD-L1) levels. These tumor properties implicate responsiveness to antiangiogenic and antiproliferative multikinase inhibitors such as lenvatinib, and immune checkpoint inhibitors such as pembrolizumab. In a retrospective study, we analyzed six patients with metastatic ATC and two patients with PDTC, who received a combination therapy of lenvatinib and pembrolizumab. Lenvatinib was started at 14-24 mg daily and combined with pembrolizumab at a fixed dose of 200 mg every three weeks. Maximum treatment duration with this combination was 40 months, and 3 of 6 ATC patients are still on therapy. Patient tumors were characterized by whole-exome sequencing and PD-L1 expression levels (tumor proportion score [TPS] 1-90%). Best overall response (BOR) within ATCs was 66% complete remissions (4/6 CR), 16% stable disease (1/6 SD), and 16% progressive disease (1/6 PD). BOR within PDTCs was partial remission (PR 2/2). The median progression-free survival was 17.75 months for all patients, and 16.5 months for ATCs, with treatment durations ranging from 1 to 40 months (1, 4, 11, 15, 19, 25, 27, and 40 months). Grade III/IV toxicities developed in 4 of 8 patients, requiring dose reduction/discontinuation of lenvatinib. The median OS was 18.5 months, with three ATC patients being still alive without relapse (40, 27, and 19 months) despite metastatic disease at the time of treatment initiation (UICC and stage IVC). All patients with long-term (>2 years) or complete responses (CRs) had either increased TMB or a PD-L1 TPS >50%. Our results implicate that the combination of lenvatinib and pembrolizumab might be safe and effective in patients with ATC/PDTC and can result in complete and long-term remissions. The combination treatment is now being systematically examined in a phase II clinical trial (Anaplastic Thyroid Carcinoma Lenvatinib Pembrolizumab [ATLEP]) in ATC/PDTC patients.
Introduction
Anaplastic thyroid carcinoma (ATC) is a rare disease with an extremely high mortality rate and a 10-year survival below 5% (1). ATCs grow very fast, infiltrate into cervical structures, such as the esophagus, trachea, or blood vessels, and metastasize to the lung, brain, and bone. Even with extensive multimodal therapy (surgery, external beam radiotherapy, and chemotherapy), the median overall survival (OS) is only 3–5 months (1–3). ATC frequently arises from differentiated thyroid carcinoma (DTC) but can also emerge de novo. Typical molecular features of ATC are mutations in TP53 (54–64%), TERT (61%), KRAS/NRAS (28–43%), BRAF (18–28%), NF1, NF2, PI3K, PTEN, and genes in the WNT signaling pathway (4–9). BRAF/MEK inhibitor combinations (dabrafenib/trametinib) are approved for BRAFV600E-mutated ATCs and have significantly enhanced survival and has high treatment response (overall response rate [ORR] 69%) (10,11). All other locally advanced or metastatic ATCs (about 75%) are individually treated with carboplatin, paclitaxel, or doxorubicin containing chemotherapeutic regimens with very modest ORR (10–20%) lasting only for a few months (progression-free survival [PFS] 3–4 months) (12–15). Poorly differentiated thyroid carcinoma (PDTC) has a more favorable prognosis, with some patients being partially responsive to radioiodine therapy (RIT), but 10-year survival is also below 10%.
Compared with DTC, ATC/PDTC are characterized by an elevated tumor mutation burden, higher programmed death ligand 1 (PD-L1) levels, and increased neoangiogenesis (VEGFR/FGFR signaling) (7,16–22), suggesting that they may be sensitivity to immune checkpoint and neoangiogenesis inhibitors.
Lenvatinib is an antiangiogenic (VEGFR 1–3/FGFR 1–4) and antiproliferative (RET/PDGFR) tyrosine kinase inhibitor (TKI), which is approved for DTC refractory to radioiodine treatment (23). PFS in DTC is 19.4 months (23–26), but it is reduced to 14.8 months in PDTC, and all patients ultimately develop treatment resistance or treatment intolerance (26). In ATC, the PFS is even shorter (5.6–7.4 months) with variable ORR between 17.4% and 43%, depending on the initial tumor stage (27–29).
Pembrolizumab is an immune checkpoint inhibitor targeting PD-1 on immune cells. Response to pembrolizumab treatment is associated with elevated expression of PD-L1 or high tumor mutational burden (TMB) (30–34). DTC have low TMB and low PD-L1 expression (CPS/TPS) and hence have low response rates to immune checkpoint inhibitor treatments (ORR 9%) (35). In ATC with higher PD-L1/TMB, the effect of immune checkpoint inhibitors is still low (ORR <10%) (36,37), as the slow response to treatment (>8 weeks) cannot keep pace with the aggressive tumor growth.
In vitro studies and mouse experiments indicate synergism between lenvatinib and pembrolizumab (38). Lenvatinib not only blocks tumor neoangiogenesis and proliferation but also enhances immune cell invasion into the tumor and therefore fosters immune responses induced by immune checkpoint inhibitors (38). Furthermore, phase II trials with the lenvatinib/pembrolizumab combination in patients with extensively pretreated metastatic solid tumors (renal, ovarian, and endometrial carcinoma) not only showed acceptable toxicity but also very promising response rates (84% partial response [PR], 16% stable disease [SD]). Phase II/III trials for endometrial, head and neck, and hepatocellular carcinoma validated the high efficacy and safety for this combination (39–42). In ATC, pembrolizumab treatment was used as a salvage strategy after patients had failed lenvatinib or dabrafenib monotherapy or a dabrafenib/trametinib combination therapy. Pembrolizumab was added to the respective TKI and induced PR rates of 43%, but with a very short PFS of only 2.96 months (43).
In contrast to this study, we directly combined lenvatinib and pembrolizumab as front-line therapy after chemotherapy failure in eight patients with metastatic ATC (n = 6) or PDTC (n = 2) and examined treatment outcome and biomarkers for this approach.
Materials and Methods
Study population and patient characteristics
This is a retrospective, single-center (University Medical Center Freiburg) cohort study of eight patients with metastatic ATC (n = 6) or PDTC (n = 2) treated with a combination of the multikinase inhibitor lenvatinib and the immune checkpoint inhibitor pembrolizumab (L/P). Patient data were collected from March 2016 to December 2019 (Table 1). ATC/PDTC diagnosis was histopathologically confirmed by the Institute for Pathology, Freiburg, in all patients. Patients had no BRAFV600E mutation, but numerous other mutations were present (Supplementary Table S1). All patients were pretreated with irradiation, chemotherapy, or RIT (Table 1 and Supplementary Table S2). Adverse events (AEs) were reported according to the National Cancer Institute Common Terminology Criteria for Adverse Events (CTCAE version 5)–GBG (Table 2). The retrospective study was approved by the Institutional Review Board (IRB) of the University Freiburg.
Table 1. Baseline Characteristics
Median age at treatment start (range), years 63.5 (49–88)
Sex, n (%)
Men 4 (50)
Women 4 (50)
Performance status, n (%)
ECOG 0 3 (37.5)
ECOG 1 3 (37.5)
ECOG 2 2 (25)
Pathological diagnosis, n (%)
ATC 6 (75)
PDTC 2 (25)
Location of metastases, n (%)
Lung 8 (100)
Bone 2 (25)
Kidney 1 (12.5)
Brain 1 (12.5)
Liver 1 (12.5)
Skin 1 (12.5)
Cervical relapse, n (%) 6 (75)
Previous therapy, n (%)
Surgery 8 (100)
Radiation ± chemosensitizing 7 (87.5)
Chemotherapy 6 (75)
RIT 2 (25)
ATC, anaplastic thyroid carcinoma; ECOG, Eastern Cooperative Oncology Group; PDTC, poorly differentiated thyroid carcinoma; RIT, radioiodine therapy.
Table 2. Adverse Events According to the Common Terminology Criteria for Adverse Events Version 5.0
Event Grade I/II (%) Grade III/IV (%)
Total 8/8 (100) 3/8 (36)
Hypertension 5/8 (63)
Fatigue 2/8 (25) 1/8 (13)
Anorexia 2/8 (25) 2/8 (25)
Oral mucositis 2/8 (25)
Joint/muscle pain 1/8 (13)
Hand–foot syndrome 1/8 (13)
Diarrhea 1/8 (13)
Proteinuria 1/8 (13)
Abdominal pain 1/8 (13)
Cervical bleeding 1/8 (13)
Data are given as totals and %. Events reported are listed in descending frequency of columns for grade I/II and grade III/IV. A patients with several multiple occurrences of an adverse event is counted only once with the highest grade. A patient with multiple adverse events is counted only once in the total row.
Treatment strategy
Patients started with lenvatinib 24 mg oral daily if the body weight (BW) was more than 80 kg, or 20 mg for BW less than 80 kg. Pembrolizumab infusions were started in between 1 and 4 weeks after initiation of lenvatinib at a fixed dose of 200 mg total every 3 weeks. Dose for lenvatinib was stepwise reduced upon occurrence of side effects according to clinical judgment. Lenvatinib was given at least for 1 year and was then stopped in patients with confirmed complete response (CR). Pembrolizumab was given for up to 40 months. It will be continued in all patients reaching a CR for two more years.
Response assessment
Radiology assessment including cervical, chest, and abdominal computed tomography (CT) scans was performed before treatment and then every 3–4 months. Response to therapy was determined centrally using the RECIST 1.1 criteria (Fig. 1A and Supplementary Table S3). Positron emission tomography (PET)–CT using [18F] fluorodeoxyglucose (FDG) (PET/CT) was performed before treatment, and after 12–16 months of treatment to confirm CRs (the European Organisation for Research and Treatment of Cancer [EORTC] response criteria for PET). In case of persistent lesions without tracer uptake on PET/CT (PR according to the RECIST 1.1 [CT scan], but CR according to the EORTC criteria for PET), lesions were surgically removed (1/8) to confirm the absence of viable tumor tissue (pathological CR criteria, Supplementary Table S4).
FIG. 1. (A) ORR after 3–4 months of treatment, 6/8 PR, 1/8 SD, 1/8 PD. (B) BOR within 16 months of treatment. (C) Lenvatinib dosage and changes over time. (D) Treatment duration and ongoing treatment. Patients in CR. BOR, best overall response; CR, complete response; ORR, overall response rate; PD, progressive disease; PR, partial response; SD, stable disease.
The efficacy of the combination treatment was assessed by ORR 3–4 months after starting treatment, best overall response (BOR) (Fig. 1B), PFS, and OS. PFS was defined as the time elapsed between starting treatment and progression or death, whichever occurred first. OS was defined as the time between starting treatment and death.
Molecular testing and immunohistochemistry
Molecular testing by whole-exome sequencing (WES) was performed from formalin-fixed and paraffin-embedded tissue specimens at the Deutsches Krebsforschungszentrum Heidelberg (DKFZ) as described previously (44,45). PD-L1 status was determined by immunohistochemistry (antibody clone SP263; Ventana) in tumor tissue specimens obtained at initial diagnosis before treatment. The tumor proportion score (TPS) was determined as proportion of PD-L1-positive tumor cells of 100 tumor cells. The combined proportion score (CPS), as amount of PD-L1-positive tumor and immune cells within 100 tumor cells, was also determined centrally at the Department of Pathology of the University Medical Center Freiburg.
Statistical analysis
Kaplan–Meier curves were used for OS and PFS. Descriptive statistics were used to summarize patients' characteristics and AEs. Statistical analysis was performed using IBM SPSS Statistics version 25.
Results
Eight patients with metastatic ATC (n = 6) or PDTC (n = 2) were treated with a combination of lenvatinib and pembrolizumab after failing chemotherapy, irradiation, or RIT (Table 1 and Supplementary Table S2). All the 8 patients had been extensively pretreated with surgery (8/8), local cervical external beam radiation therapy (6/8), RIT (2/2), local cerebral irradiation therapy (1/8), or systemic chemotherapy alone (6/8) (carboplatin/paclitaxel [4/8], cisplatin/paclitaxel [1/8], cisplatin/doxorubicin [1/8], and paclitaxel only [1/8]) (Table 1 and Supplementary Table S2). The median patient age was 66.4 years. At the beginning of treatment with lenvatinib/pembrolizumab, all patients had stage IVC. All patients had lung metastasis (8/8), and 2 of 8 skeletal metastasis, 1 of 8 liver metastasis, 1 of 8 kidney metastasis, 1 of 8 skin metastasis, and 1 of 8 brain metastasis. Six of eight patients also had progression of their local tumor. Eastern Cooperative Oncology Group (ECOG) performance status ranged from 0 to 2, with 3 ECOG 0 (38%), 3 ECOG 1 (38%), and 2 ECOG 2 (25%). Molecular diagnostics showed that none of the patients had a BRAFV600E mutation, but numerous other mutations typical for ATC/PDTC were detected and are listed in Supplementary Table S1.
Treatment regimen and AEs
Lenvatinib was started at a daily dose of 24 mg in 5 of 8 patients (BW more than 80 kg) and 20 mg in 2 patients with bodyweight less than 80 kg. An 88-year-old woman started on 14 mg/day (Fig. 1C and Table 3). Pembrolizumab treatment was initiated after a median of 2.7 weeks (ranging from 1 to 4 weeks after starting lenvatinib) and was given i.v. at a fixed dose of 200 mg every 3 weeks. In general, the therapy was well tolerated with the predominant grade II to IV AEs (AEs according to the CTCAE) being hypertension (5/8), fatigue (4/8), weight loss/anorexia (3/8), oral mucositis (2/8), diarrhea (2/8), joint/muscle pain (1/8), and hand–foot syndrome (1/8) (Table 2). The lenvatinib dose was reduced stepwise upon occurrence of intolerable side effects from 24 to 20, 14, 12, and 10 mg/day (Fig. 1C). Most side effects resolved after reducing the dose of lenvatinib, but in two patients, lenvatinib-induced AEs required treatment discontinuation (patients 3 and 6, Table 3). One grade IV serious adverse event (SAE) with a lethal cervical bleeding occurred after removal of the tracheostomy in patient 5 despite being in complete remission (Tables 2 and 3).
Table 3. Patient History
Patient Entity Age, years Prior treatment ORR in 3/4 months BOR CT+PET PFS, months OS, months Adverse events (CTCAE in grade °) Median dose lenvatinib, mg/day Current therapy/ outcome
1 PDTC 63 S Rx C/T PR PR 25 27 Hypertension °II
Fatigue °II
Anorexia °I
Oral mucositis °I 24 PD/death after stopping lenvatinib due to a knee surgery
2 ATC 76 S Rx C/T PR CR 40 40 Hypertension °II
Anorexia °II 24 Alive, CR after 12 months lenvatinib/pembrolizumab, now without treatment
3 PDTC 49 S RIT C/T PR PR 15 23 Anorexia °III
Abdominal pain °III 14 PD/death, lenvatinib on/off due to weight loss/abdominal pain
4 ATC 68 S Rx C/T PR CR 26 26 Anorexia °I
Loss of appetite °II
Proteinuria °I
Hypertension °II 20 Alive, CR after 10 months of treatment, now pembrolizumab mono
5 ATC 63 S Rx C/T PR CR 11 11 Diarrhea °II
Hypertension °II
Cervical bleeding °IV 20 CR after 7 months of treatment. Death due to cervical bleeding
6 ATC 88 S Rx C/T SD SD 4 7 Diarrhea °II
Anorexia °III
Proteinuria °II
Fatigue °III
Oral mucositis °II 14 PD/death after stopping medication due to side effects
7 ATC 64 S RIT Rx PR CR 19 19 Hypertension °II
Fatigue °II
Joint pain °II
Hand–foot syndrome °I 24 Alive, CR, lenvatinib/pembrolizumab for 12 months, now pembrolizumab mono
8 ATC 60 S R C/T PD PD 1 1 Hypertension °II 24 PD/death due to cervical tumor progression
Patient characteristics including diagnosis, previous therapy (S, RIT, Rx, C/T), patient age, PFS, ORR, BOR, OS, response after 3 months, maximum response, main side effects, median dose lenvatinib in mg/day, dose pembrolizumab, current treatment/outcome. CTCAE grades in roman numbers. Responses were assessed via the RECIST v1.1 radiology assessment and FDG uptake according to the EORTC criteria for PET.
BOR, best overall response; C/T, chemotherapy; CT, computed tomography; CR, complete response; CTCAE, Common Terminology Criteria for Adverse Events; FDG, [18F] fluorodeoxyglucose; ORR, overall response rate; OS, overall survival; PD, progressive disease; PET, positron emission tomography; PFS, progression free survival; PR, partial response; Rx, radiation therapy; S, surgery; SD, stable disease.
After four months of treatment, lenvatinib/pembrolizumab was discontinued due to severe weight loss/anorexia (grade III) in the 88-year-old patient (patient 6), and she died due to disease progression three months later. One patient was intolerant to lenvatinib treatment due to grade III abdominal pain and weight loss/anorexia (patient 3). Lenvatinib was reduced from 24 to 20 to 14 and 12 mg/day in a stepwise manner, and after 14 months, lenvatinib/pembrolizumab treatment was discontinued. Two patients received the full dose of lenvatinib 24 mg for 24 months (Fig. 1C). Pembrolizumab was given for up to 40 months and will be continued in all patients reaching a CR for two more years (Fig. 1D).
Treatment efficacy
Treatment response was first assessed 3–4 months after lenvatinib/pembrolizumab treatment. Six of eight patients had a PR according to the RECIST v1.1 criteria (Fig. 1A). ORR for ATCs was 66% (4/6 PR). The 88-year-old patient (ATC) at 14 mg lenvatinib had SD (patient 6). One ATC patient (patient 8) did not respond to lenvatinib/pembrolizumab treatment combination and died within the first month of treatment due to cervical tumor progression (1/8 progressive disease) (Fig. 1A and Supplementary Data).
BOR changed in four ATC patients from PR to CR within 16 months of treatment (total CR rate 50%, CR rate for ATC 66%) (Fig. 1B). Individual patient history is summarized in the Supplementary Data. ATC patient 2 had a confirmed CR for all target- and nontarget lesions 16 months after lenvatinib/pembrolizumab treatment, and stopped taking lenvatinib after 2 years (24 mg daily for 24 months), but continued pembrolizumab for 16 more months (40 months total). He stopped treatment for 6 months and is still in CR. ATC patient 4 with lung and brain metastases had a PR 12 months after starting treatment, but all lesions in the lung were without FDG uptake (CR according to the EORTC criteria for PET). All lung lesions were surgically removed and showed a pathological CR (no viable tumor cells). Therefore, the patient was judged as having a CR and has discontinued lenvatinib after 1 year of treatment, and continues with pembrolizumab only (26 months total). Patient 7 with a massive neck tumor and lung metastasis had a PET/CT confirmed CR 12 months after starting treatment. He stopped lenvatinib after 15 months and now continues with pembrolizumab only (19 months total). ATC patient 5 had confirmed CR 10 months after treatment start, but unfortunately died due to bleeding complications after removal of the tracheostomy tube (Table 3 and Supplementary Table S2).
Treatment durations ranged from 1 to 40 months (ATC: 40, 26, 19, 18, 4, and 1 month; PDTC: 25 and 15 months, respectively), with three patients being treated for more than 2 years (Fig. 1D). At the time of data cutoff, 3 of 8 patients (patients 2, 4, and 7, all ATCs) were still alive and on therapy (40, 26, and 19 months). We stopped the treatment of patient 2 after 40 months of treatment, and he is now regularly monitored by CT scans every 3 months. The other patients died due to disease progression (2/6 ATC, 2/2 PDTC) or hemorrhage (grade IV SAE, patient 5, Table 3). ATC patient 8 was resistant to the treatment. ATC patients 1 and 6 died shortly after discontinuation of the lenvatinib treatment caused by lenvatinib intolerance in patient 6 (grade III anorexia), and because lenvatinib had to be discontinued due to an infectious complication after a knee surgery in patient 1 (Table 3). The median PFS for the total cohort was 17.6 months, and the median OS was 19 months (Fig. 2). Data analysis for ATC only showed a median PFS of 16.8 months and a median OS of 17.3 months (Fig. 2).
FIG. 2. Kaplan–Meier curves for ATCs only and total patients. (A) PFS in all patients and ATC only. (B) OS in all patients and ATC only. ATC, anaplastic thyroid carcinoma; OS, overall survival; PFS, progression-free survival.
Biomarkers
To assess potential predictors of treatment response, we investigated the PD-L1 expression of the tumor cells and macrophages/immune cells. Furthermore, WES was performed in 7 of 8 patients, and sequences were compared to germ line sequences to assess somatic mutations and the TMB. In 1 patient (1/8), targeted sequencing for 11 frequently mutated genes (Supplementary Table S1) was performed due to low material. All tumors were positive for PD-L1 expression with a TPS ranging from 1% to 90%, and 5 of 8 patients with TPS >50% (Table 4). The CPS ranged from 5 to 100 (Table 4). Interestingly, the ATC patient with the lowest TPS (1%) and CPS 5 did not respond to the treatment (patient 8). In contrast, the patients with responses lasting more than two years and those achieving a CR all had PD-L1 TPS >50% (5/8), a CPS >75 (3/8), or a high mutation frequency above 5 mutations per megabase (3/8). The patient (patient 2) with the highest number of mutations (>1400 somatic mutations) has the longest CR duration (30 months).
Table 4. Biomarker Analysis
Patient ORR after 3/4 months (RECIST 1.1) BOR (CT/MRI/PET-CT) Response according to PET-CT TPS, % CPS Somatic mutations TMB (mutations/Mb)
1 PR PR PR 50 40 106 13.79
2 PR CR CR 60 75 1447 81.87
3 PR PR PR 10 10 79 4.08
4 PR CR CR 90 100 19 3
5 PR CR n.a. 80 100 29 3.3
6 SD SD n.a. 60 65 24 3.58
7 PR CR CR 5 7 138 5.59
8 PD PD n.a. 1 5 n.a. n.a.
CPS, combined proportion score; MRI, magnet resonance tomography; n.a., not applicable; TMB, tumor mutation burden; TPS, tumor proportion score.
Discussion
Current treatment options for ATC are limited, and response rates are low and short-lived, with marginal to absent CR (13,14). Only the small proportion of BRAFV600E-mutated ATC (about 20%) can be effectively treated with a BRAF/MEK inhibitor combination of dabrafenib and trametinib (10,11), but for the other 70–80% of ATCs, no treatment options are approved after chemotherapy failure in most countries.
ATC and PDTC are characterized by a very high proliferation rate and tumor invasiveness, driven by concurrent mutations in several pro-proliferative pathways (RAS, WNT, loss of TP53), and strongly activated VEGF/FGF signaling. PD-L1 and TMB are upregulated, but the response to single immune checkpoint inhibition often comes too late and is overrun by the aggressiveness of the disease (36).
While many kinase inhibitors (sorafenib/pazopanib) failed to show treatment efficacy in ATC (30–32), lenvatinib trials demonstrated some promising effects, with 17.4–43% PRs and up to 50% SD (27–29). CRs were absent and PFS lasted only between 77 days and 7.4 months (27–29). Besides its fast, but short-lived antiproliferative effects, lenvatinib was shown to improve immune responses to immune checkpoint inhibitors in mice. Therefore, by combining both agents, we aimed to use lenvatinib as a fast and effective bridging treatment and immuno-sensitizer for the immune checkpoint inhibitor pembrolizumab in ATC/PDTC patients.
In contrast to single-agent therapy, the combination of lenvatinib and pembrolizumab was highly effective in our treatment cohort. Eight ATC/PDTC patients who had previously been treated with several lines of therapy including chemotherapy, chemoirradiation, and even single immune checkpoint inhibition (1/8) received a combination of lenvatinib and pembrolizumab for a maximum of 40 months. The combination treatment was well tolerated and could be sustained over one year in half of the patients, and even over two years in 37% (3/8) of the patients. Half of the ATC patients (3/6) were still on therapy at data cutoff with no sustained grade III/IV toxicities despite having initially metastatic disease; three patients had confirmed CR by PET/CT and/or histopathologic examination of former metastatic sites. Seventy-five percent of all patients and 66% of the ATC patients reached a PR/CR within 16 months of treatment. The remission rates observed with lenvatinib/pembrolizumab combination in ATC/PDTC are similar to previously published data for other heavily pretreated solid tumors, such as patients with head and neck tumors, endometrial, renal cell, or hepatocellular carcinoma (39–42). As CRs and long-lasting remissions were rarely observed in ATC patients treated with lenvatinib only (27–29), the addition of pembrolizumab is most likely inducing this effect.
In patients who are already resistant to TKI treatment, the addition of pembrolizumab is only partially functional with a PFS of only 2.96 months (43), which indicates that the up-front combination of lenvatinib and pembrolizumab might be much more effective than using these drugs sequentially.
TMB and PD-L1 expression levels (TPS/CPS) are independent biomarkers for response to immune checkpoint inhibitors in solid tumors (30,46,47). In our analysis, patients reaching a CR or those who had long-term remission over two years all had a TPS above 50%, a CPS higher than 75, and/or a TMB >5/MB, indicating that those may be biomarkers for response to lenvatinib/pembrolizumab treatment in ATC/PDTC.
In general, the combination of lenvatinib and pembrolizumab was well tolerated even in the elderly patients with a higher ECOG performance status. Results are encouraging with an ORR of 75%, including a CR rate of 50% (66% in ATCs) and responses over 2 years. Therefore, the treatment results and biomarkers will be further evaluated in a phase II clinical trial with lenvatinib and pembrolizumab in ATC/PDTC patients (ATLEP trial, Anaplastic Thyroid Carcinoma Lenvatinib Pembrolizumab, EudraCT No. 2017-004570-34).
Supplementary Material
Supplemental data
Supplemental data
Supplemental data
Supplemental data
Supplemental data
Acknowledgments
Thanks to our patients and relatives for their support for this study. Thanks to Prof. Roland Mertelsmann for his continuous support and wisdom. Thanks to the molecular tumor board and the CCCF for their support.
Authors' Contributions
C.D., J.S., C.M., O.T., H.W., and N.B. wrote the article. J.R., C.K., and P.T.M. performed and evaluated PET/CTs. K.A., and S.K. performed PD-L1 staining and evaluation. M.R. designed figures. M.B. and P.M. analyzed WES data. A.Z., P.R., M.K., C.W., T.S., C.S., C.M., C.K., N.B., and K.L. treated patients and revised the article.
Author Disclosure Statement
C.D. received honoraria and travel costs for consultancy role at Eisai, AbbVie, and Gilead. M.K. received honoraria and travel costs for consultancy role at Eisai GmbH. A.Z. received honoraria and travel costs for consultancy role at Eisai, J&J, and Merck and participates in the Keynote 158 trial.
Funding Information
Resarch funding grant for IIT trials from the University of Freiburg.
Supplementary Material
Supplementary Data
Supplementary Table S1
Supplementary Table S2
Supplementary Table S3
Supplementary Table S4 | CARBOPLATIN, PACLITAXEL | DrugsGivenReaction | CC BY | 33509020 | 20,543,320 | 2021-07 |
Give an alphabetized list of all active substances of drugs taken by the patient who experienced 'Metastases to skin'. | Combination of Lenvatinib and Pembrolizumab Is an Effective Treatment Option for Anaplastic and Poorly Differentiated Thyroid Carcinoma.
Anaplastic thyroid carcinoma (ATC) and metastatic poorly differentiated thyroid carcinomas (PDTCs) are rare aggressive malignancies with poor overall survival (OS) despite extensive multimodal therapy. These tumors are highly proliferative, with frequently increased tumor mutational burden (TMB) compared with differentiated thyroid carcinomas, and elevated programmed death ligand 1 (PD-L1) levels. These tumor properties implicate responsiveness to antiangiogenic and antiproliferative multikinase inhibitors such as lenvatinib, and immune checkpoint inhibitors such as pembrolizumab. In a retrospective study, we analyzed six patients with metastatic ATC and two patients with PDTC, who received a combination therapy of lenvatinib and pembrolizumab. Lenvatinib was started at 14-24 mg daily and combined with pembrolizumab at a fixed dose of 200 mg every three weeks. Maximum treatment duration with this combination was 40 months, and 3 of 6 ATC patients are still on therapy. Patient tumors were characterized by whole-exome sequencing and PD-L1 expression levels (tumor proportion score [TPS] 1-90%). Best overall response (BOR) within ATCs was 66% complete remissions (4/6 CR), 16% stable disease (1/6 SD), and 16% progressive disease (1/6 PD). BOR within PDTCs was partial remission (PR 2/2). The median progression-free survival was 17.75 months for all patients, and 16.5 months for ATCs, with treatment durations ranging from 1 to 40 months (1, 4, 11, 15, 19, 25, 27, and 40 months). Grade III/IV toxicities developed in 4 of 8 patients, requiring dose reduction/discontinuation of lenvatinib. The median OS was 18.5 months, with three ATC patients being still alive without relapse (40, 27, and 19 months) despite metastatic disease at the time of treatment initiation (UICC and stage IVC). All patients with long-term (>2 years) or complete responses (CRs) had either increased TMB or a PD-L1 TPS >50%. Our results implicate that the combination of lenvatinib and pembrolizumab might be safe and effective in patients with ATC/PDTC and can result in complete and long-term remissions. The combination treatment is now being systematically examined in a phase II clinical trial (Anaplastic Thyroid Carcinoma Lenvatinib Pembrolizumab [ATLEP]) in ATC/PDTC patients.
Introduction
Anaplastic thyroid carcinoma (ATC) is a rare disease with an extremely high mortality rate and a 10-year survival below 5% (1). ATCs grow very fast, infiltrate into cervical structures, such as the esophagus, trachea, or blood vessels, and metastasize to the lung, brain, and bone. Even with extensive multimodal therapy (surgery, external beam radiotherapy, and chemotherapy), the median overall survival (OS) is only 3–5 months (1–3). ATC frequently arises from differentiated thyroid carcinoma (DTC) but can also emerge de novo. Typical molecular features of ATC are mutations in TP53 (54–64%), TERT (61%), KRAS/NRAS (28–43%), BRAF (18–28%), NF1, NF2, PI3K, PTEN, and genes in the WNT signaling pathway (4–9). BRAF/MEK inhibitor combinations (dabrafenib/trametinib) are approved for BRAFV600E-mutated ATCs and have significantly enhanced survival and has high treatment response (overall response rate [ORR] 69%) (10,11). All other locally advanced or metastatic ATCs (about 75%) are individually treated with carboplatin, paclitaxel, or doxorubicin containing chemotherapeutic regimens with very modest ORR (10–20%) lasting only for a few months (progression-free survival [PFS] 3–4 months) (12–15). Poorly differentiated thyroid carcinoma (PDTC) has a more favorable prognosis, with some patients being partially responsive to radioiodine therapy (RIT), but 10-year survival is also below 10%.
Compared with DTC, ATC/PDTC are characterized by an elevated tumor mutation burden, higher programmed death ligand 1 (PD-L1) levels, and increased neoangiogenesis (VEGFR/FGFR signaling) (7,16–22), suggesting that they may be sensitivity to immune checkpoint and neoangiogenesis inhibitors.
Lenvatinib is an antiangiogenic (VEGFR 1–3/FGFR 1–4) and antiproliferative (RET/PDGFR) tyrosine kinase inhibitor (TKI), which is approved for DTC refractory to radioiodine treatment (23). PFS in DTC is 19.4 months (23–26), but it is reduced to 14.8 months in PDTC, and all patients ultimately develop treatment resistance or treatment intolerance (26). In ATC, the PFS is even shorter (5.6–7.4 months) with variable ORR between 17.4% and 43%, depending on the initial tumor stage (27–29).
Pembrolizumab is an immune checkpoint inhibitor targeting PD-1 on immune cells. Response to pembrolizumab treatment is associated with elevated expression of PD-L1 or high tumor mutational burden (TMB) (30–34). DTC have low TMB and low PD-L1 expression (CPS/TPS) and hence have low response rates to immune checkpoint inhibitor treatments (ORR 9%) (35). In ATC with higher PD-L1/TMB, the effect of immune checkpoint inhibitors is still low (ORR <10%) (36,37), as the slow response to treatment (>8 weeks) cannot keep pace with the aggressive tumor growth.
In vitro studies and mouse experiments indicate synergism between lenvatinib and pembrolizumab (38). Lenvatinib not only blocks tumor neoangiogenesis and proliferation but also enhances immune cell invasion into the tumor and therefore fosters immune responses induced by immune checkpoint inhibitors (38). Furthermore, phase II trials with the lenvatinib/pembrolizumab combination in patients with extensively pretreated metastatic solid tumors (renal, ovarian, and endometrial carcinoma) not only showed acceptable toxicity but also very promising response rates (84% partial response [PR], 16% stable disease [SD]). Phase II/III trials for endometrial, head and neck, and hepatocellular carcinoma validated the high efficacy and safety for this combination (39–42). In ATC, pembrolizumab treatment was used as a salvage strategy after patients had failed lenvatinib or dabrafenib monotherapy or a dabrafenib/trametinib combination therapy. Pembrolizumab was added to the respective TKI and induced PR rates of 43%, but with a very short PFS of only 2.96 months (43).
In contrast to this study, we directly combined lenvatinib and pembrolizumab as front-line therapy after chemotherapy failure in eight patients with metastatic ATC (n = 6) or PDTC (n = 2) and examined treatment outcome and biomarkers for this approach.
Materials and Methods
Study population and patient characteristics
This is a retrospective, single-center (University Medical Center Freiburg) cohort study of eight patients with metastatic ATC (n = 6) or PDTC (n = 2) treated with a combination of the multikinase inhibitor lenvatinib and the immune checkpoint inhibitor pembrolizumab (L/P). Patient data were collected from March 2016 to December 2019 (Table 1). ATC/PDTC diagnosis was histopathologically confirmed by the Institute for Pathology, Freiburg, in all patients. Patients had no BRAFV600E mutation, but numerous other mutations were present (Supplementary Table S1). All patients were pretreated with irradiation, chemotherapy, or RIT (Table 1 and Supplementary Table S2). Adverse events (AEs) were reported according to the National Cancer Institute Common Terminology Criteria for Adverse Events (CTCAE version 5)–GBG (Table 2). The retrospective study was approved by the Institutional Review Board (IRB) of the University Freiburg.
Table 1. Baseline Characteristics
Median age at treatment start (range), years 63.5 (49–88)
Sex, n (%)
Men 4 (50)
Women 4 (50)
Performance status, n (%)
ECOG 0 3 (37.5)
ECOG 1 3 (37.5)
ECOG 2 2 (25)
Pathological diagnosis, n (%)
ATC 6 (75)
PDTC 2 (25)
Location of metastases, n (%)
Lung 8 (100)
Bone 2 (25)
Kidney 1 (12.5)
Brain 1 (12.5)
Liver 1 (12.5)
Skin 1 (12.5)
Cervical relapse, n (%) 6 (75)
Previous therapy, n (%)
Surgery 8 (100)
Radiation ± chemosensitizing 7 (87.5)
Chemotherapy 6 (75)
RIT 2 (25)
ATC, anaplastic thyroid carcinoma; ECOG, Eastern Cooperative Oncology Group; PDTC, poorly differentiated thyroid carcinoma; RIT, radioiodine therapy.
Table 2. Adverse Events According to the Common Terminology Criteria for Adverse Events Version 5.0
Event Grade I/II (%) Grade III/IV (%)
Total 8/8 (100) 3/8 (36)
Hypertension 5/8 (63)
Fatigue 2/8 (25) 1/8 (13)
Anorexia 2/8 (25) 2/8 (25)
Oral mucositis 2/8 (25)
Joint/muscle pain 1/8 (13)
Hand–foot syndrome 1/8 (13)
Diarrhea 1/8 (13)
Proteinuria 1/8 (13)
Abdominal pain 1/8 (13)
Cervical bleeding 1/8 (13)
Data are given as totals and %. Events reported are listed in descending frequency of columns for grade I/II and grade III/IV. A patients with several multiple occurrences of an adverse event is counted only once with the highest grade. A patient with multiple adverse events is counted only once in the total row.
Treatment strategy
Patients started with lenvatinib 24 mg oral daily if the body weight (BW) was more than 80 kg, or 20 mg for BW less than 80 kg. Pembrolizumab infusions were started in between 1 and 4 weeks after initiation of lenvatinib at a fixed dose of 200 mg total every 3 weeks. Dose for lenvatinib was stepwise reduced upon occurrence of side effects according to clinical judgment. Lenvatinib was given at least for 1 year and was then stopped in patients with confirmed complete response (CR). Pembrolizumab was given for up to 40 months. It will be continued in all patients reaching a CR for two more years.
Response assessment
Radiology assessment including cervical, chest, and abdominal computed tomography (CT) scans was performed before treatment and then every 3–4 months. Response to therapy was determined centrally using the RECIST 1.1 criteria (Fig. 1A and Supplementary Table S3). Positron emission tomography (PET)–CT using [18F] fluorodeoxyglucose (FDG) (PET/CT) was performed before treatment, and after 12–16 months of treatment to confirm CRs (the European Organisation for Research and Treatment of Cancer [EORTC] response criteria for PET). In case of persistent lesions without tracer uptake on PET/CT (PR according to the RECIST 1.1 [CT scan], but CR according to the EORTC criteria for PET), lesions were surgically removed (1/8) to confirm the absence of viable tumor tissue (pathological CR criteria, Supplementary Table S4).
FIG. 1. (A) ORR after 3–4 months of treatment, 6/8 PR, 1/8 SD, 1/8 PD. (B) BOR within 16 months of treatment. (C) Lenvatinib dosage and changes over time. (D) Treatment duration and ongoing treatment. Patients in CR. BOR, best overall response; CR, complete response; ORR, overall response rate; PD, progressive disease; PR, partial response; SD, stable disease.
The efficacy of the combination treatment was assessed by ORR 3–4 months after starting treatment, best overall response (BOR) (Fig. 1B), PFS, and OS. PFS was defined as the time elapsed between starting treatment and progression or death, whichever occurred first. OS was defined as the time between starting treatment and death.
Molecular testing and immunohistochemistry
Molecular testing by whole-exome sequencing (WES) was performed from formalin-fixed and paraffin-embedded tissue specimens at the Deutsches Krebsforschungszentrum Heidelberg (DKFZ) as described previously (44,45). PD-L1 status was determined by immunohistochemistry (antibody clone SP263; Ventana) in tumor tissue specimens obtained at initial diagnosis before treatment. The tumor proportion score (TPS) was determined as proportion of PD-L1-positive tumor cells of 100 tumor cells. The combined proportion score (CPS), as amount of PD-L1-positive tumor and immune cells within 100 tumor cells, was also determined centrally at the Department of Pathology of the University Medical Center Freiburg.
Statistical analysis
Kaplan–Meier curves were used for OS and PFS. Descriptive statistics were used to summarize patients' characteristics and AEs. Statistical analysis was performed using IBM SPSS Statistics version 25.
Results
Eight patients with metastatic ATC (n = 6) or PDTC (n = 2) were treated with a combination of lenvatinib and pembrolizumab after failing chemotherapy, irradiation, or RIT (Table 1 and Supplementary Table S2). All the 8 patients had been extensively pretreated with surgery (8/8), local cervical external beam radiation therapy (6/8), RIT (2/2), local cerebral irradiation therapy (1/8), or systemic chemotherapy alone (6/8) (carboplatin/paclitaxel [4/8], cisplatin/paclitaxel [1/8], cisplatin/doxorubicin [1/8], and paclitaxel only [1/8]) (Table 1 and Supplementary Table S2). The median patient age was 66.4 years. At the beginning of treatment with lenvatinib/pembrolizumab, all patients had stage IVC. All patients had lung metastasis (8/8), and 2 of 8 skeletal metastasis, 1 of 8 liver metastasis, 1 of 8 kidney metastasis, 1 of 8 skin metastasis, and 1 of 8 brain metastasis. Six of eight patients also had progression of their local tumor. Eastern Cooperative Oncology Group (ECOG) performance status ranged from 0 to 2, with 3 ECOG 0 (38%), 3 ECOG 1 (38%), and 2 ECOG 2 (25%). Molecular diagnostics showed that none of the patients had a BRAFV600E mutation, but numerous other mutations typical for ATC/PDTC were detected and are listed in Supplementary Table S1.
Treatment regimen and AEs
Lenvatinib was started at a daily dose of 24 mg in 5 of 8 patients (BW more than 80 kg) and 20 mg in 2 patients with bodyweight less than 80 kg. An 88-year-old woman started on 14 mg/day (Fig. 1C and Table 3). Pembrolizumab treatment was initiated after a median of 2.7 weeks (ranging from 1 to 4 weeks after starting lenvatinib) and was given i.v. at a fixed dose of 200 mg every 3 weeks. In general, the therapy was well tolerated with the predominant grade II to IV AEs (AEs according to the CTCAE) being hypertension (5/8), fatigue (4/8), weight loss/anorexia (3/8), oral mucositis (2/8), diarrhea (2/8), joint/muscle pain (1/8), and hand–foot syndrome (1/8) (Table 2). The lenvatinib dose was reduced stepwise upon occurrence of intolerable side effects from 24 to 20, 14, 12, and 10 mg/day (Fig. 1C). Most side effects resolved after reducing the dose of lenvatinib, but in two patients, lenvatinib-induced AEs required treatment discontinuation (patients 3 and 6, Table 3). One grade IV serious adverse event (SAE) with a lethal cervical bleeding occurred after removal of the tracheostomy in patient 5 despite being in complete remission (Tables 2 and 3).
Table 3. Patient History
Patient Entity Age, years Prior treatment ORR in 3/4 months BOR CT+PET PFS, months OS, months Adverse events (CTCAE in grade °) Median dose lenvatinib, mg/day Current therapy/ outcome
1 PDTC 63 S Rx C/T PR PR 25 27 Hypertension °II
Fatigue °II
Anorexia °I
Oral mucositis °I 24 PD/death after stopping lenvatinib due to a knee surgery
2 ATC 76 S Rx C/T PR CR 40 40 Hypertension °II
Anorexia °II 24 Alive, CR after 12 months lenvatinib/pembrolizumab, now without treatment
3 PDTC 49 S RIT C/T PR PR 15 23 Anorexia °III
Abdominal pain °III 14 PD/death, lenvatinib on/off due to weight loss/abdominal pain
4 ATC 68 S Rx C/T PR CR 26 26 Anorexia °I
Loss of appetite °II
Proteinuria °I
Hypertension °II 20 Alive, CR after 10 months of treatment, now pembrolizumab mono
5 ATC 63 S Rx C/T PR CR 11 11 Diarrhea °II
Hypertension °II
Cervical bleeding °IV 20 CR after 7 months of treatment. Death due to cervical bleeding
6 ATC 88 S Rx C/T SD SD 4 7 Diarrhea °II
Anorexia °III
Proteinuria °II
Fatigue °III
Oral mucositis °II 14 PD/death after stopping medication due to side effects
7 ATC 64 S RIT Rx PR CR 19 19 Hypertension °II
Fatigue °II
Joint pain °II
Hand–foot syndrome °I 24 Alive, CR, lenvatinib/pembrolizumab for 12 months, now pembrolizumab mono
8 ATC 60 S R C/T PD PD 1 1 Hypertension °II 24 PD/death due to cervical tumor progression
Patient characteristics including diagnosis, previous therapy (S, RIT, Rx, C/T), patient age, PFS, ORR, BOR, OS, response after 3 months, maximum response, main side effects, median dose lenvatinib in mg/day, dose pembrolizumab, current treatment/outcome. CTCAE grades in roman numbers. Responses were assessed via the RECIST v1.1 radiology assessment and FDG uptake according to the EORTC criteria for PET.
BOR, best overall response; C/T, chemotherapy; CT, computed tomography; CR, complete response; CTCAE, Common Terminology Criteria for Adverse Events; FDG, [18F] fluorodeoxyglucose; ORR, overall response rate; OS, overall survival; PD, progressive disease; PET, positron emission tomography; PFS, progression free survival; PR, partial response; Rx, radiation therapy; S, surgery; SD, stable disease.
After four months of treatment, lenvatinib/pembrolizumab was discontinued due to severe weight loss/anorexia (grade III) in the 88-year-old patient (patient 6), and she died due to disease progression three months later. One patient was intolerant to lenvatinib treatment due to grade III abdominal pain and weight loss/anorexia (patient 3). Lenvatinib was reduced from 24 to 20 to 14 and 12 mg/day in a stepwise manner, and after 14 months, lenvatinib/pembrolizumab treatment was discontinued. Two patients received the full dose of lenvatinib 24 mg for 24 months (Fig. 1C). Pembrolizumab was given for up to 40 months and will be continued in all patients reaching a CR for two more years (Fig. 1D).
Treatment efficacy
Treatment response was first assessed 3–4 months after lenvatinib/pembrolizumab treatment. Six of eight patients had a PR according to the RECIST v1.1 criteria (Fig. 1A). ORR for ATCs was 66% (4/6 PR). The 88-year-old patient (ATC) at 14 mg lenvatinib had SD (patient 6). One ATC patient (patient 8) did not respond to lenvatinib/pembrolizumab treatment combination and died within the first month of treatment due to cervical tumor progression (1/8 progressive disease) (Fig. 1A and Supplementary Data).
BOR changed in four ATC patients from PR to CR within 16 months of treatment (total CR rate 50%, CR rate for ATC 66%) (Fig. 1B). Individual patient history is summarized in the Supplementary Data. ATC patient 2 had a confirmed CR for all target- and nontarget lesions 16 months after lenvatinib/pembrolizumab treatment, and stopped taking lenvatinib after 2 years (24 mg daily for 24 months), but continued pembrolizumab for 16 more months (40 months total). He stopped treatment for 6 months and is still in CR. ATC patient 4 with lung and brain metastases had a PR 12 months after starting treatment, but all lesions in the lung were without FDG uptake (CR according to the EORTC criteria for PET). All lung lesions were surgically removed and showed a pathological CR (no viable tumor cells). Therefore, the patient was judged as having a CR and has discontinued lenvatinib after 1 year of treatment, and continues with pembrolizumab only (26 months total). Patient 7 with a massive neck tumor and lung metastasis had a PET/CT confirmed CR 12 months after starting treatment. He stopped lenvatinib after 15 months and now continues with pembrolizumab only (19 months total). ATC patient 5 had confirmed CR 10 months after treatment start, but unfortunately died due to bleeding complications after removal of the tracheostomy tube (Table 3 and Supplementary Table S2).
Treatment durations ranged from 1 to 40 months (ATC: 40, 26, 19, 18, 4, and 1 month; PDTC: 25 and 15 months, respectively), with three patients being treated for more than 2 years (Fig. 1D). At the time of data cutoff, 3 of 8 patients (patients 2, 4, and 7, all ATCs) were still alive and on therapy (40, 26, and 19 months). We stopped the treatment of patient 2 after 40 months of treatment, and he is now regularly monitored by CT scans every 3 months. The other patients died due to disease progression (2/6 ATC, 2/2 PDTC) or hemorrhage (grade IV SAE, patient 5, Table 3). ATC patient 8 was resistant to the treatment. ATC patients 1 and 6 died shortly after discontinuation of the lenvatinib treatment caused by lenvatinib intolerance in patient 6 (grade III anorexia), and because lenvatinib had to be discontinued due to an infectious complication after a knee surgery in patient 1 (Table 3). The median PFS for the total cohort was 17.6 months, and the median OS was 19 months (Fig. 2). Data analysis for ATC only showed a median PFS of 16.8 months and a median OS of 17.3 months (Fig. 2).
FIG. 2. Kaplan–Meier curves for ATCs only and total patients. (A) PFS in all patients and ATC only. (B) OS in all patients and ATC only. ATC, anaplastic thyroid carcinoma; OS, overall survival; PFS, progression-free survival.
Biomarkers
To assess potential predictors of treatment response, we investigated the PD-L1 expression of the tumor cells and macrophages/immune cells. Furthermore, WES was performed in 7 of 8 patients, and sequences were compared to germ line sequences to assess somatic mutations and the TMB. In 1 patient (1/8), targeted sequencing for 11 frequently mutated genes (Supplementary Table S1) was performed due to low material. All tumors were positive for PD-L1 expression with a TPS ranging from 1% to 90%, and 5 of 8 patients with TPS >50% (Table 4). The CPS ranged from 5 to 100 (Table 4). Interestingly, the ATC patient with the lowest TPS (1%) and CPS 5 did not respond to the treatment (patient 8). In contrast, the patients with responses lasting more than two years and those achieving a CR all had PD-L1 TPS >50% (5/8), a CPS >75 (3/8), or a high mutation frequency above 5 mutations per megabase (3/8). The patient (patient 2) with the highest number of mutations (>1400 somatic mutations) has the longest CR duration (30 months).
Table 4. Biomarker Analysis
Patient ORR after 3/4 months (RECIST 1.1) BOR (CT/MRI/PET-CT) Response according to PET-CT TPS, % CPS Somatic mutations TMB (mutations/Mb)
1 PR PR PR 50 40 106 13.79
2 PR CR CR 60 75 1447 81.87
3 PR PR PR 10 10 79 4.08
4 PR CR CR 90 100 19 3
5 PR CR n.a. 80 100 29 3.3
6 SD SD n.a. 60 65 24 3.58
7 PR CR CR 5 7 138 5.59
8 PD PD n.a. 1 5 n.a. n.a.
CPS, combined proportion score; MRI, magnet resonance tomography; n.a., not applicable; TMB, tumor mutation burden; TPS, tumor proportion score.
Discussion
Current treatment options for ATC are limited, and response rates are low and short-lived, with marginal to absent CR (13,14). Only the small proportion of BRAFV600E-mutated ATC (about 20%) can be effectively treated with a BRAF/MEK inhibitor combination of dabrafenib and trametinib (10,11), but for the other 70–80% of ATCs, no treatment options are approved after chemotherapy failure in most countries.
ATC and PDTC are characterized by a very high proliferation rate and tumor invasiveness, driven by concurrent mutations in several pro-proliferative pathways (RAS, WNT, loss of TP53), and strongly activated VEGF/FGF signaling. PD-L1 and TMB are upregulated, but the response to single immune checkpoint inhibition often comes too late and is overrun by the aggressiveness of the disease (36).
While many kinase inhibitors (sorafenib/pazopanib) failed to show treatment efficacy in ATC (30–32), lenvatinib trials demonstrated some promising effects, with 17.4–43% PRs and up to 50% SD (27–29). CRs were absent and PFS lasted only between 77 days and 7.4 months (27–29). Besides its fast, but short-lived antiproliferative effects, lenvatinib was shown to improve immune responses to immune checkpoint inhibitors in mice. Therefore, by combining both agents, we aimed to use lenvatinib as a fast and effective bridging treatment and immuno-sensitizer for the immune checkpoint inhibitor pembrolizumab in ATC/PDTC patients.
In contrast to single-agent therapy, the combination of lenvatinib and pembrolizumab was highly effective in our treatment cohort. Eight ATC/PDTC patients who had previously been treated with several lines of therapy including chemotherapy, chemoirradiation, and even single immune checkpoint inhibition (1/8) received a combination of lenvatinib and pembrolizumab for a maximum of 40 months. The combination treatment was well tolerated and could be sustained over one year in half of the patients, and even over two years in 37% (3/8) of the patients. Half of the ATC patients (3/6) were still on therapy at data cutoff with no sustained grade III/IV toxicities despite having initially metastatic disease; three patients had confirmed CR by PET/CT and/or histopathologic examination of former metastatic sites. Seventy-five percent of all patients and 66% of the ATC patients reached a PR/CR within 16 months of treatment. The remission rates observed with lenvatinib/pembrolizumab combination in ATC/PDTC are similar to previously published data for other heavily pretreated solid tumors, such as patients with head and neck tumors, endometrial, renal cell, or hepatocellular carcinoma (39–42). As CRs and long-lasting remissions were rarely observed in ATC patients treated with lenvatinib only (27–29), the addition of pembrolizumab is most likely inducing this effect.
In patients who are already resistant to TKI treatment, the addition of pembrolizumab is only partially functional with a PFS of only 2.96 months (43), which indicates that the up-front combination of lenvatinib and pembrolizumab might be much more effective than using these drugs sequentially.
TMB and PD-L1 expression levels (TPS/CPS) are independent biomarkers for response to immune checkpoint inhibitors in solid tumors (30,46,47). In our analysis, patients reaching a CR or those who had long-term remission over two years all had a TPS above 50%, a CPS higher than 75, and/or a TMB >5/MB, indicating that those may be biomarkers for response to lenvatinib/pembrolizumab treatment in ATC/PDTC.
In general, the combination of lenvatinib and pembrolizumab was well tolerated even in the elderly patients with a higher ECOG performance status. Results are encouraging with an ORR of 75%, including a CR rate of 50% (66% in ATCs) and responses over 2 years. Therefore, the treatment results and biomarkers will be further evaluated in a phase II clinical trial with lenvatinib and pembrolizumab in ATC/PDTC patients (ATLEP trial, Anaplastic Thyroid Carcinoma Lenvatinib Pembrolizumab, EudraCT No. 2017-004570-34).
Supplementary Material
Supplemental data
Supplemental data
Supplemental data
Supplemental data
Supplemental data
Acknowledgments
Thanks to our patients and relatives for their support for this study. Thanks to Prof. Roland Mertelsmann for his continuous support and wisdom. Thanks to the molecular tumor board and the CCCF for their support.
Authors' Contributions
C.D., J.S., C.M., O.T., H.W., and N.B. wrote the article. J.R., C.K., and P.T.M. performed and evaluated PET/CTs. K.A., and S.K. performed PD-L1 staining and evaluation. M.R. designed figures. M.B. and P.M. analyzed WES data. A.Z., P.R., M.K., C.W., T.S., C.S., C.M., C.K., N.B., and K.L. treated patients and revised the article.
Author Disclosure Statement
C.D. received honoraria and travel costs for consultancy role at Eisai, AbbVie, and Gilead. M.K. received honoraria and travel costs for consultancy role at Eisai GmbH. A.Z. received honoraria and travel costs for consultancy role at Eisai, J&J, and Merck and participates in the Keynote 158 trial.
Funding Information
Resarch funding grant for IIT trials from the University of Freiburg.
Supplementary Material
Supplementary Data
Supplementary Table S1
Supplementary Table S2
Supplementary Table S3
Supplementary Table S4 | CARBOPLATIN, PACLITAXEL | DrugsGivenReaction | CC BY | 33509020 | 20,559,963 | 2021-07 |
Give an alphabetized list of all active substances of drugs taken by the patient who experienced 'Oesophageal carcinoma'. | Combination of Lenvatinib and Pembrolizumab Is an Effective Treatment Option for Anaplastic and Poorly Differentiated Thyroid Carcinoma.
Anaplastic thyroid carcinoma (ATC) and metastatic poorly differentiated thyroid carcinomas (PDTCs) are rare aggressive malignancies with poor overall survival (OS) despite extensive multimodal therapy. These tumors are highly proliferative, with frequently increased tumor mutational burden (TMB) compared with differentiated thyroid carcinomas, and elevated programmed death ligand 1 (PD-L1) levels. These tumor properties implicate responsiveness to antiangiogenic and antiproliferative multikinase inhibitors such as lenvatinib, and immune checkpoint inhibitors such as pembrolizumab. In a retrospective study, we analyzed six patients with metastatic ATC and two patients with PDTC, who received a combination therapy of lenvatinib and pembrolizumab. Lenvatinib was started at 14-24 mg daily and combined with pembrolizumab at a fixed dose of 200 mg every three weeks. Maximum treatment duration with this combination was 40 months, and 3 of 6 ATC patients are still on therapy. Patient tumors were characterized by whole-exome sequencing and PD-L1 expression levels (tumor proportion score [TPS] 1-90%). Best overall response (BOR) within ATCs was 66% complete remissions (4/6 CR), 16% stable disease (1/6 SD), and 16% progressive disease (1/6 PD). BOR within PDTCs was partial remission (PR 2/2). The median progression-free survival was 17.75 months for all patients, and 16.5 months for ATCs, with treatment durations ranging from 1 to 40 months (1, 4, 11, 15, 19, 25, 27, and 40 months). Grade III/IV toxicities developed in 4 of 8 patients, requiring dose reduction/discontinuation of lenvatinib. The median OS was 18.5 months, with three ATC patients being still alive without relapse (40, 27, and 19 months) despite metastatic disease at the time of treatment initiation (UICC and stage IVC). All patients with long-term (>2 years) or complete responses (CRs) had either increased TMB or a PD-L1 TPS >50%. Our results implicate that the combination of lenvatinib and pembrolizumab might be safe and effective in patients with ATC/PDTC and can result in complete and long-term remissions. The combination treatment is now being systematically examined in a phase II clinical trial (Anaplastic Thyroid Carcinoma Lenvatinib Pembrolizumab [ATLEP]) in ATC/PDTC patients.
Introduction
Anaplastic thyroid carcinoma (ATC) is a rare disease with an extremely high mortality rate and a 10-year survival below 5% (1). ATCs grow very fast, infiltrate into cervical structures, such as the esophagus, trachea, or blood vessels, and metastasize to the lung, brain, and bone. Even with extensive multimodal therapy (surgery, external beam radiotherapy, and chemotherapy), the median overall survival (OS) is only 3–5 months (1–3). ATC frequently arises from differentiated thyroid carcinoma (DTC) but can also emerge de novo. Typical molecular features of ATC are mutations in TP53 (54–64%), TERT (61%), KRAS/NRAS (28–43%), BRAF (18–28%), NF1, NF2, PI3K, PTEN, and genes in the WNT signaling pathway (4–9). BRAF/MEK inhibitor combinations (dabrafenib/trametinib) are approved for BRAFV600E-mutated ATCs and have significantly enhanced survival and has high treatment response (overall response rate [ORR] 69%) (10,11). All other locally advanced or metastatic ATCs (about 75%) are individually treated with carboplatin, paclitaxel, or doxorubicin containing chemotherapeutic regimens with very modest ORR (10–20%) lasting only for a few months (progression-free survival [PFS] 3–4 months) (12–15). Poorly differentiated thyroid carcinoma (PDTC) has a more favorable prognosis, with some patients being partially responsive to radioiodine therapy (RIT), but 10-year survival is also below 10%.
Compared with DTC, ATC/PDTC are characterized by an elevated tumor mutation burden, higher programmed death ligand 1 (PD-L1) levels, and increased neoangiogenesis (VEGFR/FGFR signaling) (7,16–22), suggesting that they may be sensitivity to immune checkpoint and neoangiogenesis inhibitors.
Lenvatinib is an antiangiogenic (VEGFR 1–3/FGFR 1–4) and antiproliferative (RET/PDGFR) tyrosine kinase inhibitor (TKI), which is approved for DTC refractory to radioiodine treatment (23). PFS in DTC is 19.4 months (23–26), but it is reduced to 14.8 months in PDTC, and all patients ultimately develop treatment resistance or treatment intolerance (26). In ATC, the PFS is even shorter (5.6–7.4 months) with variable ORR between 17.4% and 43%, depending on the initial tumor stage (27–29).
Pembrolizumab is an immune checkpoint inhibitor targeting PD-1 on immune cells. Response to pembrolizumab treatment is associated with elevated expression of PD-L1 or high tumor mutational burden (TMB) (30–34). DTC have low TMB and low PD-L1 expression (CPS/TPS) and hence have low response rates to immune checkpoint inhibitor treatments (ORR 9%) (35). In ATC with higher PD-L1/TMB, the effect of immune checkpoint inhibitors is still low (ORR <10%) (36,37), as the slow response to treatment (>8 weeks) cannot keep pace with the aggressive tumor growth.
In vitro studies and mouse experiments indicate synergism between lenvatinib and pembrolizumab (38). Lenvatinib not only blocks tumor neoangiogenesis and proliferation but also enhances immune cell invasion into the tumor and therefore fosters immune responses induced by immune checkpoint inhibitors (38). Furthermore, phase II trials with the lenvatinib/pembrolizumab combination in patients with extensively pretreated metastatic solid tumors (renal, ovarian, and endometrial carcinoma) not only showed acceptable toxicity but also very promising response rates (84% partial response [PR], 16% stable disease [SD]). Phase II/III trials for endometrial, head and neck, and hepatocellular carcinoma validated the high efficacy and safety for this combination (39–42). In ATC, pembrolizumab treatment was used as a salvage strategy after patients had failed lenvatinib or dabrafenib monotherapy or a dabrafenib/trametinib combination therapy. Pembrolizumab was added to the respective TKI and induced PR rates of 43%, but with a very short PFS of only 2.96 months (43).
In contrast to this study, we directly combined lenvatinib and pembrolizumab as front-line therapy after chemotherapy failure in eight patients with metastatic ATC (n = 6) or PDTC (n = 2) and examined treatment outcome and biomarkers for this approach.
Materials and Methods
Study population and patient characteristics
This is a retrospective, single-center (University Medical Center Freiburg) cohort study of eight patients with metastatic ATC (n = 6) or PDTC (n = 2) treated with a combination of the multikinase inhibitor lenvatinib and the immune checkpoint inhibitor pembrolizumab (L/P). Patient data were collected from March 2016 to December 2019 (Table 1). ATC/PDTC diagnosis was histopathologically confirmed by the Institute for Pathology, Freiburg, in all patients. Patients had no BRAFV600E mutation, but numerous other mutations were present (Supplementary Table S1). All patients were pretreated with irradiation, chemotherapy, or RIT (Table 1 and Supplementary Table S2). Adverse events (AEs) were reported according to the National Cancer Institute Common Terminology Criteria for Adverse Events (CTCAE version 5)–GBG (Table 2). The retrospective study was approved by the Institutional Review Board (IRB) of the University Freiburg.
Table 1. Baseline Characteristics
Median age at treatment start (range), years 63.5 (49–88)
Sex, n (%)
Men 4 (50)
Women 4 (50)
Performance status, n (%)
ECOG 0 3 (37.5)
ECOG 1 3 (37.5)
ECOG 2 2 (25)
Pathological diagnosis, n (%)
ATC 6 (75)
PDTC 2 (25)
Location of metastases, n (%)
Lung 8 (100)
Bone 2 (25)
Kidney 1 (12.5)
Brain 1 (12.5)
Liver 1 (12.5)
Skin 1 (12.5)
Cervical relapse, n (%) 6 (75)
Previous therapy, n (%)
Surgery 8 (100)
Radiation ± chemosensitizing 7 (87.5)
Chemotherapy 6 (75)
RIT 2 (25)
ATC, anaplastic thyroid carcinoma; ECOG, Eastern Cooperative Oncology Group; PDTC, poorly differentiated thyroid carcinoma; RIT, radioiodine therapy.
Table 2. Adverse Events According to the Common Terminology Criteria for Adverse Events Version 5.0
Event Grade I/II (%) Grade III/IV (%)
Total 8/8 (100) 3/8 (36)
Hypertension 5/8 (63)
Fatigue 2/8 (25) 1/8 (13)
Anorexia 2/8 (25) 2/8 (25)
Oral mucositis 2/8 (25)
Joint/muscle pain 1/8 (13)
Hand–foot syndrome 1/8 (13)
Diarrhea 1/8 (13)
Proteinuria 1/8 (13)
Abdominal pain 1/8 (13)
Cervical bleeding 1/8 (13)
Data are given as totals and %. Events reported are listed in descending frequency of columns for grade I/II and grade III/IV. A patients with several multiple occurrences of an adverse event is counted only once with the highest grade. A patient with multiple adverse events is counted only once in the total row.
Treatment strategy
Patients started with lenvatinib 24 mg oral daily if the body weight (BW) was more than 80 kg, or 20 mg for BW less than 80 kg. Pembrolizumab infusions were started in between 1 and 4 weeks after initiation of lenvatinib at a fixed dose of 200 mg total every 3 weeks. Dose for lenvatinib was stepwise reduced upon occurrence of side effects according to clinical judgment. Lenvatinib was given at least for 1 year and was then stopped in patients with confirmed complete response (CR). Pembrolizumab was given for up to 40 months. It will be continued in all patients reaching a CR for two more years.
Response assessment
Radiology assessment including cervical, chest, and abdominal computed tomography (CT) scans was performed before treatment and then every 3–4 months. Response to therapy was determined centrally using the RECIST 1.1 criteria (Fig. 1A and Supplementary Table S3). Positron emission tomography (PET)–CT using [18F] fluorodeoxyglucose (FDG) (PET/CT) was performed before treatment, and after 12–16 months of treatment to confirm CRs (the European Organisation for Research and Treatment of Cancer [EORTC] response criteria for PET). In case of persistent lesions without tracer uptake on PET/CT (PR according to the RECIST 1.1 [CT scan], but CR according to the EORTC criteria for PET), lesions were surgically removed (1/8) to confirm the absence of viable tumor tissue (pathological CR criteria, Supplementary Table S4).
FIG. 1. (A) ORR after 3–4 months of treatment, 6/8 PR, 1/8 SD, 1/8 PD. (B) BOR within 16 months of treatment. (C) Lenvatinib dosage and changes over time. (D) Treatment duration and ongoing treatment. Patients in CR. BOR, best overall response; CR, complete response; ORR, overall response rate; PD, progressive disease; PR, partial response; SD, stable disease.
The efficacy of the combination treatment was assessed by ORR 3–4 months after starting treatment, best overall response (BOR) (Fig. 1B), PFS, and OS. PFS was defined as the time elapsed between starting treatment and progression or death, whichever occurred first. OS was defined as the time between starting treatment and death.
Molecular testing and immunohistochemistry
Molecular testing by whole-exome sequencing (WES) was performed from formalin-fixed and paraffin-embedded tissue specimens at the Deutsches Krebsforschungszentrum Heidelberg (DKFZ) as described previously (44,45). PD-L1 status was determined by immunohistochemistry (antibody clone SP263; Ventana) in tumor tissue specimens obtained at initial diagnosis before treatment. The tumor proportion score (TPS) was determined as proportion of PD-L1-positive tumor cells of 100 tumor cells. The combined proportion score (CPS), as amount of PD-L1-positive tumor and immune cells within 100 tumor cells, was also determined centrally at the Department of Pathology of the University Medical Center Freiburg.
Statistical analysis
Kaplan–Meier curves were used for OS and PFS. Descriptive statistics were used to summarize patients' characteristics and AEs. Statistical analysis was performed using IBM SPSS Statistics version 25.
Results
Eight patients with metastatic ATC (n = 6) or PDTC (n = 2) were treated with a combination of lenvatinib and pembrolizumab after failing chemotherapy, irradiation, or RIT (Table 1 and Supplementary Table S2). All the 8 patients had been extensively pretreated with surgery (8/8), local cervical external beam radiation therapy (6/8), RIT (2/2), local cerebral irradiation therapy (1/8), or systemic chemotherapy alone (6/8) (carboplatin/paclitaxel [4/8], cisplatin/paclitaxel [1/8], cisplatin/doxorubicin [1/8], and paclitaxel only [1/8]) (Table 1 and Supplementary Table S2). The median patient age was 66.4 years. At the beginning of treatment with lenvatinib/pembrolizumab, all patients had stage IVC. All patients had lung metastasis (8/8), and 2 of 8 skeletal metastasis, 1 of 8 liver metastasis, 1 of 8 kidney metastasis, 1 of 8 skin metastasis, and 1 of 8 brain metastasis. Six of eight patients also had progression of their local tumor. Eastern Cooperative Oncology Group (ECOG) performance status ranged from 0 to 2, with 3 ECOG 0 (38%), 3 ECOG 1 (38%), and 2 ECOG 2 (25%). Molecular diagnostics showed that none of the patients had a BRAFV600E mutation, but numerous other mutations typical for ATC/PDTC were detected and are listed in Supplementary Table S1.
Treatment regimen and AEs
Lenvatinib was started at a daily dose of 24 mg in 5 of 8 patients (BW more than 80 kg) and 20 mg in 2 patients with bodyweight less than 80 kg. An 88-year-old woman started on 14 mg/day (Fig. 1C and Table 3). Pembrolizumab treatment was initiated after a median of 2.7 weeks (ranging from 1 to 4 weeks after starting lenvatinib) and was given i.v. at a fixed dose of 200 mg every 3 weeks. In general, the therapy was well tolerated with the predominant grade II to IV AEs (AEs according to the CTCAE) being hypertension (5/8), fatigue (4/8), weight loss/anorexia (3/8), oral mucositis (2/8), diarrhea (2/8), joint/muscle pain (1/8), and hand–foot syndrome (1/8) (Table 2). The lenvatinib dose was reduced stepwise upon occurrence of intolerable side effects from 24 to 20, 14, 12, and 10 mg/day (Fig. 1C). Most side effects resolved after reducing the dose of lenvatinib, but in two patients, lenvatinib-induced AEs required treatment discontinuation (patients 3 and 6, Table 3). One grade IV serious adverse event (SAE) with a lethal cervical bleeding occurred after removal of the tracheostomy in patient 5 despite being in complete remission (Tables 2 and 3).
Table 3. Patient History
Patient Entity Age, years Prior treatment ORR in 3/4 months BOR CT+PET PFS, months OS, months Adverse events (CTCAE in grade °) Median dose lenvatinib, mg/day Current therapy/ outcome
1 PDTC 63 S Rx C/T PR PR 25 27 Hypertension °II
Fatigue °II
Anorexia °I
Oral mucositis °I 24 PD/death after stopping lenvatinib due to a knee surgery
2 ATC 76 S Rx C/T PR CR 40 40 Hypertension °II
Anorexia °II 24 Alive, CR after 12 months lenvatinib/pembrolizumab, now without treatment
3 PDTC 49 S RIT C/T PR PR 15 23 Anorexia °III
Abdominal pain °III 14 PD/death, lenvatinib on/off due to weight loss/abdominal pain
4 ATC 68 S Rx C/T PR CR 26 26 Anorexia °I
Loss of appetite °II
Proteinuria °I
Hypertension °II 20 Alive, CR after 10 months of treatment, now pembrolizumab mono
5 ATC 63 S Rx C/T PR CR 11 11 Diarrhea °II
Hypertension °II
Cervical bleeding °IV 20 CR after 7 months of treatment. Death due to cervical bleeding
6 ATC 88 S Rx C/T SD SD 4 7 Diarrhea °II
Anorexia °III
Proteinuria °II
Fatigue °III
Oral mucositis °II 14 PD/death after stopping medication due to side effects
7 ATC 64 S RIT Rx PR CR 19 19 Hypertension °II
Fatigue °II
Joint pain °II
Hand–foot syndrome °I 24 Alive, CR, lenvatinib/pembrolizumab for 12 months, now pembrolizumab mono
8 ATC 60 S R C/T PD PD 1 1 Hypertension °II 24 PD/death due to cervical tumor progression
Patient characteristics including diagnosis, previous therapy (S, RIT, Rx, C/T), patient age, PFS, ORR, BOR, OS, response after 3 months, maximum response, main side effects, median dose lenvatinib in mg/day, dose pembrolizumab, current treatment/outcome. CTCAE grades in roman numbers. Responses were assessed via the RECIST v1.1 radiology assessment and FDG uptake according to the EORTC criteria for PET.
BOR, best overall response; C/T, chemotherapy; CT, computed tomography; CR, complete response; CTCAE, Common Terminology Criteria for Adverse Events; FDG, [18F] fluorodeoxyglucose; ORR, overall response rate; OS, overall survival; PD, progressive disease; PET, positron emission tomography; PFS, progression free survival; PR, partial response; Rx, radiation therapy; S, surgery; SD, stable disease.
After four months of treatment, lenvatinib/pembrolizumab was discontinued due to severe weight loss/anorexia (grade III) in the 88-year-old patient (patient 6), and she died due to disease progression three months later. One patient was intolerant to lenvatinib treatment due to grade III abdominal pain and weight loss/anorexia (patient 3). Lenvatinib was reduced from 24 to 20 to 14 and 12 mg/day in a stepwise manner, and after 14 months, lenvatinib/pembrolizumab treatment was discontinued. Two patients received the full dose of lenvatinib 24 mg for 24 months (Fig. 1C). Pembrolizumab was given for up to 40 months and will be continued in all patients reaching a CR for two more years (Fig. 1D).
Treatment efficacy
Treatment response was first assessed 3–4 months after lenvatinib/pembrolizumab treatment. Six of eight patients had a PR according to the RECIST v1.1 criteria (Fig. 1A). ORR for ATCs was 66% (4/6 PR). The 88-year-old patient (ATC) at 14 mg lenvatinib had SD (patient 6). One ATC patient (patient 8) did not respond to lenvatinib/pembrolizumab treatment combination and died within the first month of treatment due to cervical tumor progression (1/8 progressive disease) (Fig. 1A and Supplementary Data).
BOR changed in four ATC patients from PR to CR within 16 months of treatment (total CR rate 50%, CR rate for ATC 66%) (Fig. 1B). Individual patient history is summarized in the Supplementary Data. ATC patient 2 had a confirmed CR for all target- and nontarget lesions 16 months after lenvatinib/pembrolizumab treatment, and stopped taking lenvatinib after 2 years (24 mg daily for 24 months), but continued pembrolizumab for 16 more months (40 months total). He stopped treatment for 6 months and is still in CR. ATC patient 4 with lung and brain metastases had a PR 12 months after starting treatment, but all lesions in the lung were without FDG uptake (CR according to the EORTC criteria for PET). All lung lesions were surgically removed and showed a pathological CR (no viable tumor cells). Therefore, the patient was judged as having a CR and has discontinued lenvatinib after 1 year of treatment, and continues with pembrolizumab only (26 months total). Patient 7 with a massive neck tumor and lung metastasis had a PET/CT confirmed CR 12 months after starting treatment. He stopped lenvatinib after 15 months and now continues with pembrolizumab only (19 months total). ATC patient 5 had confirmed CR 10 months after treatment start, but unfortunately died due to bleeding complications after removal of the tracheostomy tube (Table 3 and Supplementary Table S2).
Treatment durations ranged from 1 to 40 months (ATC: 40, 26, 19, 18, 4, and 1 month; PDTC: 25 and 15 months, respectively), with three patients being treated for more than 2 years (Fig. 1D). At the time of data cutoff, 3 of 8 patients (patients 2, 4, and 7, all ATCs) were still alive and on therapy (40, 26, and 19 months). We stopped the treatment of patient 2 after 40 months of treatment, and he is now regularly monitored by CT scans every 3 months. The other patients died due to disease progression (2/6 ATC, 2/2 PDTC) or hemorrhage (grade IV SAE, patient 5, Table 3). ATC patient 8 was resistant to the treatment. ATC patients 1 and 6 died shortly after discontinuation of the lenvatinib treatment caused by lenvatinib intolerance in patient 6 (grade III anorexia), and because lenvatinib had to be discontinued due to an infectious complication after a knee surgery in patient 1 (Table 3). The median PFS for the total cohort was 17.6 months, and the median OS was 19 months (Fig. 2). Data analysis for ATC only showed a median PFS of 16.8 months and a median OS of 17.3 months (Fig. 2).
FIG. 2. Kaplan–Meier curves for ATCs only and total patients. (A) PFS in all patients and ATC only. (B) OS in all patients and ATC only. ATC, anaplastic thyroid carcinoma; OS, overall survival; PFS, progression-free survival.
Biomarkers
To assess potential predictors of treatment response, we investigated the PD-L1 expression of the tumor cells and macrophages/immune cells. Furthermore, WES was performed in 7 of 8 patients, and sequences were compared to germ line sequences to assess somatic mutations and the TMB. In 1 patient (1/8), targeted sequencing for 11 frequently mutated genes (Supplementary Table S1) was performed due to low material. All tumors were positive for PD-L1 expression with a TPS ranging from 1% to 90%, and 5 of 8 patients with TPS >50% (Table 4). The CPS ranged from 5 to 100 (Table 4). Interestingly, the ATC patient with the lowest TPS (1%) and CPS 5 did not respond to the treatment (patient 8). In contrast, the patients with responses lasting more than two years and those achieving a CR all had PD-L1 TPS >50% (5/8), a CPS >75 (3/8), or a high mutation frequency above 5 mutations per megabase (3/8). The patient (patient 2) with the highest number of mutations (>1400 somatic mutations) has the longest CR duration (30 months).
Table 4. Biomarker Analysis
Patient ORR after 3/4 months (RECIST 1.1) BOR (CT/MRI/PET-CT) Response according to PET-CT TPS, % CPS Somatic mutations TMB (mutations/Mb)
1 PR PR PR 50 40 106 13.79
2 PR CR CR 60 75 1447 81.87
3 PR PR PR 10 10 79 4.08
4 PR CR CR 90 100 19 3
5 PR CR n.a. 80 100 29 3.3
6 SD SD n.a. 60 65 24 3.58
7 PR CR CR 5 7 138 5.59
8 PD PD n.a. 1 5 n.a. n.a.
CPS, combined proportion score; MRI, magnet resonance tomography; n.a., not applicable; TMB, tumor mutation burden; TPS, tumor proportion score.
Discussion
Current treatment options for ATC are limited, and response rates are low and short-lived, with marginal to absent CR (13,14). Only the small proportion of BRAFV600E-mutated ATC (about 20%) can be effectively treated with a BRAF/MEK inhibitor combination of dabrafenib and trametinib (10,11), but for the other 70–80% of ATCs, no treatment options are approved after chemotherapy failure in most countries.
ATC and PDTC are characterized by a very high proliferation rate and tumor invasiveness, driven by concurrent mutations in several pro-proliferative pathways (RAS, WNT, loss of TP53), and strongly activated VEGF/FGF signaling. PD-L1 and TMB are upregulated, but the response to single immune checkpoint inhibition often comes too late and is overrun by the aggressiveness of the disease (36).
While many kinase inhibitors (sorafenib/pazopanib) failed to show treatment efficacy in ATC (30–32), lenvatinib trials demonstrated some promising effects, with 17.4–43% PRs and up to 50% SD (27–29). CRs were absent and PFS lasted only between 77 days and 7.4 months (27–29). Besides its fast, but short-lived antiproliferative effects, lenvatinib was shown to improve immune responses to immune checkpoint inhibitors in mice. Therefore, by combining both agents, we aimed to use lenvatinib as a fast and effective bridging treatment and immuno-sensitizer for the immune checkpoint inhibitor pembrolizumab in ATC/PDTC patients.
In contrast to single-agent therapy, the combination of lenvatinib and pembrolizumab was highly effective in our treatment cohort. Eight ATC/PDTC patients who had previously been treated with several lines of therapy including chemotherapy, chemoirradiation, and even single immune checkpoint inhibition (1/8) received a combination of lenvatinib and pembrolizumab for a maximum of 40 months. The combination treatment was well tolerated and could be sustained over one year in half of the patients, and even over two years in 37% (3/8) of the patients. Half of the ATC patients (3/6) were still on therapy at data cutoff with no sustained grade III/IV toxicities despite having initially metastatic disease; three patients had confirmed CR by PET/CT and/or histopathologic examination of former metastatic sites. Seventy-five percent of all patients and 66% of the ATC patients reached a PR/CR within 16 months of treatment. The remission rates observed with lenvatinib/pembrolizumab combination in ATC/PDTC are similar to previously published data for other heavily pretreated solid tumors, such as patients with head and neck tumors, endometrial, renal cell, or hepatocellular carcinoma (39–42). As CRs and long-lasting remissions were rarely observed in ATC patients treated with lenvatinib only (27–29), the addition of pembrolizumab is most likely inducing this effect.
In patients who are already resistant to TKI treatment, the addition of pembrolizumab is only partially functional with a PFS of only 2.96 months (43), which indicates that the up-front combination of lenvatinib and pembrolizumab might be much more effective than using these drugs sequentially.
TMB and PD-L1 expression levels (TPS/CPS) are independent biomarkers for response to immune checkpoint inhibitors in solid tumors (30,46,47). In our analysis, patients reaching a CR or those who had long-term remission over two years all had a TPS above 50%, a CPS higher than 75, and/or a TMB >5/MB, indicating that those may be biomarkers for response to lenvatinib/pembrolizumab treatment in ATC/PDTC.
In general, the combination of lenvatinib and pembrolizumab was well tolerated even in the elderly patients with a higher ECOG performance status. Results are encouraging with an ORR of 75%, including a CR rate of 50% (66% in ATCs) and responses over 2 years. Therefore, the treatment results and biomarkers will be further evaluated in a phase II clinical trial with lenvatinib and pembrolizumab in ATC/PDTC patients (ATLEP trial, Anaplastic Thyroid Carcinoma Lenvatinib Pembrolizumab, EudraCT No. 2017-004570-34).
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Supplemental data
Acknowledgments
Thanks to our patients and relatives for their support for this study. Thanks to Prof. Roland Mertelsmann for his continuous support and wisdom. Thanks to the molecular tumor board and the CCCF for their support.
Authors' Contributions
C.D., J.S., C.M., O.T., H.W., and N.B. wrote the article. J.R., C.K., and P.T.M. performed and evaluated PET/CTs. K.A., and S.K. performed PD-L1 staining and evaluation. M.R. designed figures. M.B. and P.M. analyzed WES data. A.Z., P.R., M.K., C.W., T.S., C.S., C.M., C.K., N.B., and K.L. treated patients and revised the article.
Author Disclosure Statement
C.D. received honoraria and travel costs for consultancy role at Eisai, AbbVie, and Gilead. M.K. received honoraria and travel costs for consultancy role at Eisai GmbH. A.Z. received honoraria and travel costs for consultancy role at Eisai, J&J, and Merck and participates in the Keynote 158 trial.
Funding Information
Resarch funding grant for IIT trials from the University of Freiburg.
Supplementary Material
Supplementary Data
Supplementary Table S1
Supplementary Table S2
Supplementary Table S3
Supplementary Table S4 | CARBOPLATIN, PACLITAXEL | DrugsGivenReaction | CC BY | 33509020 | 20,554,496 | 2021-07 |
Give an alphabetized list of all active substances of drugs taken by the patient who experienced 'Product use in unapproved indication'. | Combination of Lenvatinib and Pembrolizumab Is an Effective Treatment Option for Anaplastic and Poorly Differentiated Thyroid Carcinoma.
Anaplastic thyroid carcinoma (ATC) and metastatic poorly differentiated thyroid carcinomas (PDTCs) are rare aggressive malignancies with poor overall survival (OS) despite extensive multimodal therapy. These tumors are highly proliferative, with frequently increased tumor mutational burden (TMB) compared with differentiated thyroid carcinomas, and elevated programmed death ligand 1 (PD-L1) levels. These tumor properties implicate responsiveness to antiangiogenic and antiproliferative multikinase inhibitors such as lenvatinib, and immune checkpoint inhibitors such as pembrolizumab. In a retrospective study, we analyzed six patients with metastatic ATC and two patients with PDTC, who received a combination therapy of lenvatinib and pembrolizumab. Lenvatinib was started at 14-24 mg daily and combined with pembrolizumab at a fixed dose of 200 mg every three weeks. Maximum treatment duration with this combination was 40 months, and 3 of 6 ATC patients are still on therapy. Patient tumors were characterized by whole-exome sequencing and PD-L1 expression levels (tumor proportion score [TPS] 1-90%). Best overall response (BOR) within ATCs was 66% complete remissions (4/6 CR), 16% stable disease (1/6 SD), and 16% progressive disease (1/6 PD). BOR within PDTCs was partial remission (PR 2/2). The median progression-free survival was 17.75 months for all patients, and 16.5 months for ATCs, with treatment durations ranging from 1 to 40 months (1, 4, 11, 15, 19, 25, 27, and 40 months). Grade III/IV toxicities developed in 4 of 8 patients, requiring dose reduction/discontinuation of lenvatinib. The median OS was 18.5 months, with three ATC patients being still alive without relapse (40, 27, and 19 months) despite metastatic disease at the time of treatment initiation (UICC and stage IVC). All patients with long-term (>2 years) or complete responses (CRs) had either increased TMB or a PD-L1 TPS >50%. Our results implicate that the combination of lenvatinib and pembrolizumab might be safe and effective in patients with ATC/PDTC and can result in complete and long-term remissions. The combination treatment is now being systematically examined in a phase II clinical trial (Anaplastic Thyroid Carcinoma Lenvatinib Pembrolizumab [ATLEP]) in ATC/PDTC patients.
Introduction
Anaplastic thyroid carcinoma (ATC) is a rare disease with an extremely high mortality rate and a 10-year survival below 5% (1). ATCs grow very fast, infiltrate into cervical structures, such as the esophagus, trachea, or blood vessels, and metastasize to the lung, brain, and bone. Even with extensive multimodal therapy (surgery, external beam radiotherapy, and chemotherapy), the median overall survival (OS) is only 3–5 months (1–3). ATC frequently arises from differentiated thyroid carcinoma (DTC) but can also emerge de novo. Typical molecular features of ATC are mutations in TP53 (54–64%), TERT (61%), KRAS/NRAS (28–43%), BRAF (18–28%), NF1, NF2, PI3K, PTEN, and genes in the WNT signaling pathway (4–9). BRAF/MEK inhibitor combinations (dabrafenib/trametinib) are approved for BRAFV600E-mutated ATCs and have significantly enhanced survival and has high treatment response (overall response rate [ORR] 69%) (10,11). All other locally advanced or metastatic ATCs (about 75%) are individually treated with carboplatin, paclitaxel, or doxorubicin containing chemotherapeutic regimens with very modest ORR (10–20%) lasting only for a few months (progression-free survival [PFS] 3–4 months) (12–15). Poorly differentiated thyroid carcinoma (PDTC) has a more favorable prognosis, with some patients being partially responsive to radioiodine therapy (RIT), but 10-year survival is also below 10%.
Compared with DTC, ATC/PDTC are characterized by an elevated tumor mutation burden, higher programmed death ligand 1 (PD-L1) levels, and increased neoangiogenesis (VEGFR/FGFR signaling) (7,16–22), suggesting that they may be sensitivity to immune checkpoint and neoangiogenesis inhibitors.
Lenvatinib is an antiangiogenic (VEGFR 1–3/FGFR 1–4) and antiproliferative (RET/PDGFR) tyrosine kinase inhibitor (TKI), which is approved for DTC refractory to radioiodine treatment (23). PFS in DTC is 19.4 months (23–26), but it is reduced to 14.8 months in PDTC, and all patients ultimately develop treatment resistance or treatment intolerance (26). In ATC, the PFS is even shorter (5.6–7.4 months) with variable ORR between 17.4% and 43%, depending on the initial tumor stage (27–29).
Pembrolizumab is an immune checkpoint inhibitor targeting PD-1 on immune cells. Response to pembrolizumab treatment is associated with elevated expression of PD-L1 or high tumor mutational burden (TMB) (30–34). DTC have low TMB and low PD-L1 expression (CPS/TPS) and hence have low response rates to immune checkpoint inhibitor treatments (ORR 9%) (35). In ATC with higher PD-L1/TMB, the effect of immune checkpoint inhibitors is still low (ORR <10%) (36,37), as the slow response to treatment (>8 weeks) cannot keep pace with the aggressive tumor growth.
In vitro studies and mouse experiments indicate synergism between lenvatinib and pembrolizumab (38). Lenvatinib not only blocks tumor neoangiogenesis and proliferation but also enhances immune cell invasion into the tumor and therefore fosters immune responses induced by immune checkpoint inhibitors (38). Furthermore, phase II trials with the lenvatinib/pembrolizumab combination in patients with extensively pretreated metastatic solid tumors (renal, ovarian, and endometrial carcinoma) not only showed acceptable toxicity but also very promising response rates (84% partial response [PR], 16% stable disease [SD]). Phase II/III trials for endometrial, head and neck, and hepatocellular carcinoma validated the high efficacy and safety for this combination (39–42). In ATC, pembrolizumab treatment was used as a salvage strategy after patients had failed lenvatinib or dabrafenib monotherapy or a dabrafenib/trametinib combination therapy. Pembrolizumab was added to the respective TKI and induced PR rates of 43%, but with a very short PFS of only 2.96 months (43).
In contrast to this study, we directly combined lenvatinib and pembrolizumab as front-line therapy after chemotherapy failure in eight patients with metastatic ATC (n = 6) or PDTC (n = 2) and examined treatment outcome and biomarkers for this approach.
Materials and Methods
Study population and patient characteristics
This is a retrospective, single-center (University Medical Center Freiburg) cohort study of eight patients with metastatic ATC (n = 6) or PDTC (n = 2) treated with a combination of the multikinase inhibitor lenvatinib and the immune checkpoint inhibitor pembrolizumab (L/P). Patient data were collected from March 2016 to December 2019 (Table 1). ATC/PDTC diagnosis was histopathologically confirmed by the Institute for Pathology, Freiburg, in all patients. Patients had no BRAFV600E mutation, but numerous other mutations were present (Supplementary Table S1). All patients were pretreated with irradiation, chemotherapy, or RIT (Table 1 and Supplementary Table S2). Adverse events (AEs) were reported according to the National Cancer Institute Common Terminology Criteria for Adverse Events (CTCAE version 5)–GBG (Table 2). The retrospective study was approved by the Institutional Review Board (IRB) of the University Freiburg.
Table 1. Baseline Characteristics
Median age at treatment start (range), years 63.5 (49–88)
Sex, n (%)
Men 4 (50)
Women 4 (50)
Performance status, n (%)
ECOG 0 3 (37.5)
ECOG 1 3 (37.5)
ECOG 2 2 (25)
Pathological diagnosis, n (%)
ATC 6 (75)
PDTC 2 (25)
Location of metastases, n (%)
Lung 8 (100)
Bone 2 (25)
Kidney 1 (12.5)
Brain 1 (12.5)
Liver 1 (12.5)
Skin 1 (12.5)
Cervical relapse, n (%) 6 (75)
Previous therapy, n (%)
Surgery 8 (100)
Radiation ± chemosensitizing 7 (87.5)
Chemotherapy 6 (75)
RIT 2 (25)
ATC, anaplastic thyroid carcinoma; ECOG, Eastern Cooperative Oncology Group; PDTC, poorly differentiated thyroid carcinoma; RIT, radioiodine therapy.
Table 2. Adverse Events According to the Common Terminology Criteria for Adverse Events Version 5.0
Event Grade I/II (%) Grade III/IV (%)
Total 8/8 (100) 3/8 (36)
Hypertension 5/8 (63)
Fatigue 2/8 (25) 1/8 (13)
Anorexia 2/8 (25) 2/8 (25)
Oral mucositis 2/8 (25)
Joint/muscle pain 1/8 (13)
Hand–foot syndrome 1/8 (13)
Diarrhea 1/8 (13)
Proteinuria 1/8 (13)
Abdominal pain 1/8 (13)
Cervical bleeding 1/8 (13)
Data are given as totals and %. Events reported are listed in descending frequency of columns for grade I/II and grade III/IV. A patients with several multiple occurrences of an adverse event is counted only once with the highest grade. A patient with multiple adverse events is counted only once in the total row.
Treatment strategy
Patients started with lenvatinib 24 mg oral daily if the body weight (BW) was more than 80 kg, or 20 mg for BW less than 80 kg. Pembrolizumab infusions were started in between 1 and 4 weeks after initiation of lenvatinib at a fixed dose of 200 mg total every 3 weeks. Dose for lenvatinib was stepwise reduced upon occurrence of side effects according to clinical judgment. Lenvatinib was given at least for 1 year and was then stopped in patients with confirmed complete response (CR). Pembrolizumab was given for up to 40 months. It will be continued in all patients reaching a CR for two more years.
Response assessment
Radiology assessment including cervical, chest, and abdominal computed tomography (CT) scans was performed before treatment and then every 3–4 months. Response to therapy was determined centrally using the RECIST 1.1 criteria (Fig. 1A and Supplementary Table S3). Positron emission tomography (PET)–CT using [18F] fluorodeoxyglucose (FDG) (PET/CT) was performed before treatment, and after 12–16 months of treatment to confirm CRs (the European Organisation for Research and Treatment of Cancer [EORTC] response criteria for PET). In case of persistent lesions without tracer uptake on PET/CT (PR according to the RECIST 1.1 [CT scan], but CR according to the EORTC criteria for PET), lesions were surgically removed (1/8) to confirm the absence of viable tumor tissue (pathological CR criteria, Supplementary Table S4).
FIG. 1. (A) ORR after 3–4 months of treatment, 6/8 PR, 1/8 SD, 1/8 PD. (B) BOR within 16 months of treatment. (C) Lenvatinib dosage and changes over time. (D) Treatment duration and ongoing treatment. Patients in CR. BOR, best overall response; CR, complete response; ORR, overall response rate; PD, progressive disease; PR, partial response; SD, stable disease.
The efficacy of the combination treatment was assessed by ORR 3–4 months after starting treatment, best overall response (BOR) (Fig. 1B), PFS, and OS. PFS was defined as the time elapsed between starting treatment and progression or death, whichever occurred first. OS was defined as the time between starting treatment and death.
Molecular testing and immunohistochemistry
Molecular testing by whole-exome sequencing (WES) was performed from formalin-fixed and paraffin-embedded tissue specimens at the Deutsches Krebsforschungszentrum Heidelberg (DKFZ) as described previously (44,45). PD-L1 status was determined by immunohistochemistry (antibody clone SP263; Ventana) in tumor tissue specimens obtained at initial diagnosis before treatment. The tumor proportion score (TPS) was determined as proportion of PD-L1-positive tumor cells of 100 tumor cells. The combined proportion score (CPS), as amount of PD-L1-positive tumor and immune cells within 100 tumor cells, was also determined centrally at the Department of Pathology of the University Medical Center Freiburg.
Statistical analysis
Kaplan–Meier curves were used for OS and PFS. Descriptive statistics were used to summarize patients' characteristics and AEs. Statistical analysis was performed using IBM SPSS Statistics version 25.
Results
Eight patients with metastatic ATC (n = 6) or PDTC (n = 2) were treated with a combination of lenvatinib and pembrolizumab after failing chemotherapy, irradiation, or RIT (Table 1 and Supplementary Table S2). All the 8 patients had been extensively pretreated with surgery (8/8), local cervical external beam radiation therapy (6/8), RIT (2/2), local cerebral irradiation therapy (1/8), or systemic chemotherapy alone (6/8) (carboplatin/paclitaxel [4/8], cisplatin/paclitaxel [1/8], cisplatin/doxorubicin [1/8], and paclitaxel only [1/8]) (Table 1 and Supplementary Table S2). The median patient age was 66.4 years. At the beginning of treatment with lenvatinib/pembrolizumab, all patients had stage IVC. All patients had lung metastasis (8/8), and 2 of 8 skeletal metastasis, 1 of 8 liver metastasis, 1 of 8 kidney metastasis, 1 of 8 skin metastasis, and 1 of 8 brain metastasis. Six of eight patients also had progression of their local tumor. Eastern Cooperative Oncology Group (ECOG) performance status ranged from 0 to 2, with 3 ECOG 0 (38%), 3 ECOG 1 (38%), and 2 ECOG 2 (25%). Molecular diagnostics showed that none of the patients had a BRAFV600E mutation, but numerous other mutations typical for ATC/PDTC were detected and are listed in Supplementary Table S1.
Treatment regimen and AEs
Lenvatinib was started at a daily dose of 24 mg in 5 of 8 patients (BW more than 80 kg) and 20 mg in 2 patients with bodyweight less than 80 kg. An 88-year-old woman started on 14 mg/day (Fig. 1C and Table 3). Pembrolizumab treatment was initiated after a median of 2.7 weeks (ranging from 1 to 4 weeks after starting lenvatinib) and was given i.v. at a fixed dose of 200 mg every 3 weeks. In general, the therapy was well tolerated with the predominant grade II to IV AEs (AEs according to the CTCAE) being hypertension (5/8), fatigue (4/8), weight loss/anorexia (3/8), oral mucositis (2/8), diarrhea (2/8), joint/muscle pain (1/8), and hand–foot syndrome (1/8) (Table 2). The lenvatinib dose was reduced stepwise upon occurrence of intolerable side effects from 24 to 20, 14, 12, and 10 mg/day (Fig. 1C). Most side effects resolved after reducing the dose of lenvatinib, but in two patients, lenvatinib-induced AEs required treatment discontinuation (patients 3 and 6, Table 3). One grade IV serious adverse event (SAE) with a lethal cervical bleeding occurred after removal of the tracheostomy in patient 5 despite being in complete remission (Tables 2 and 3).
Table 3. Patient History
Patient Entity Age, years Prior treatment ORR in 3/4 months BOR CT+PET PFS, months OS, months Adverse events (CTCAE in grade °) Median dose lenvatinib, mg/day Current therapy/ outcome
1 PDTC 63 S Rx C/T PR PR 25 27 Hypertension °II
Fatigue °II
Anorexia °I
Oral mucositis °I 24 PD/death after stopping lenvatinib due to a knee surgery
2 ATC 76 S Rx C/T PR CR 40 40 Hypertension °II
Anorexia °II 24 Alive, CR after 12 months lenvatinib/pembrolizumab, now without treatment
3 PDTC 49 S RIT C/T PR PR 15 23 Anorexia °III
Abdominal pain °III 14 PD/death, lenvatinib on/off due to weight loss/abdominal pain
4 ATC 68 S Rx C/T PR CR 26 26 Anorexia °I
Loss of appetite °II
Proteinuria °I
Hypertension °II 20 Alive, CR after 10 months of treatment, now pembrolizumab mono
5 ATC 63 S Rx C/T PR CR 11 11 Diarrhea °II
Hypertension °II
Cervical bleeding °IV 20 CR after 7 months of treatment. Death due to cervical bleeding
6 ATC 88 S Rx C/T SD SD 4 7 Diarrhea °II
Anorexia °III
Proteinuria °II
Fatigue °III
Oral mucositis °II 14 PD/death after stopping medication due to side effects
7 ATC 64 S RIT Rx PR CR 19 19 Hypertension °II
Fatigue °II
Joint pain °II
Hand–foot syndrome °I 24 Alive, CR, lenvatinib/pembrolizumab for 12 months, now pembrolizumab mono
8 ATC 60 S R C/T PD PD 1 1 Hypertension °II 24 PD/death due to cervical tumor progression
Patient characteristics including diagnosis, previous therapy (S, RIT, Rx, C/T), patient age, PFS, ORR, BOR, OS, response after 3 months, maximum response, main side effects, median dose lenvatinib in mg/day, dose pembrolizumab, current treatment/outcome. CTCAE grades in roman numbers. Responses were assessed via the RECIST v1.1 radiology assessment and FDG uptake according to the EORTC criteria for PET.
BOR, best overall response; C/T, chemotherapy; CT, computed tomography; CR, complete response; CTCAE, Common Terminology Criteria for Adverse Events; FDG, [18F] fluorodeoxyglucose; ORR, overall response rate; OS, overall survival; PD, progressive disease; PET, positron emission tomography; PFS, progression free survival; PR, partial response; Rx, radiation therapy; S, surgery; SD, stable disease.
After four months of treatment, lenvatinib/pembrolizumab was discontinued due to severe weight loss/anorexia (grade III) in the 88-year-old patient (patient 6), and she died due to disease progression three months later. One patient was intolerant to lenvatinib treatment due to grade III abdominal pain and weight loss/anorexia (patient 3). Lenvatinib was reduced from 24 to 20 to 14 and 12 mg/day in a stepwise manner, and after 14 months, lenvatinib/pembrolizumab treatment was discontinued. Two patients received the full dose of lenvatinib 24 mg for 24 months (Fig. 1C). Pembrolizumab was given for up to 40 months and will be continued in all patients reaching a CR for two more years (Fig. 1D).
Treatment efficacy
Treatment response was first assessed 3–4 months after lenvatinib/pembrolizumab treatment. Six of eight patients had a PR according to the RECIST v1.1 criteria (Fig. 1A). ORR for ATCs was 66% (4/6 PR). The 88-year-old patient (ATC) at 14 mg lenvatinib had SD (patient 6). One ATC patient (patient 8) did not respond to lenvatinib/pembrolizumab treatment combination and died within the first month of treatment due to cervical tumor progression (1/8 progressive disease) (Fig. 1A and Supplementary Data).
BOR changed in four ATC patients from PR to CR within 16 months of treatment (total CR rate 50%, CR rate for ATC 66%) (Fig. 1B). Individual patient history is summarized in the Supplementary Data. ATC patient 2 had a confirmed CR for all target- and nontarget lesions 16 months after lenvatinib/pembrolizumab treatment, and stopped taking lenvatinib after 2 years (24 mg daily for 24 months), but continued pembrolizumab for 16 more months (40 months total). He stopped treatment for 6 months and is still in CR. ATC patient 4 with lung and brain metastases had a PR 12 months after starting treatment, but all lesions in the lung were without FDG uptake (CR according to the EORTC criteria for PET). All lung lesions were surgically removed and showed a pathological CR (no viable tumor cells). Therefore, the patient was judged as having a CR and has discontinued lenvatinib after 1 year of treatment, and continues with pembrolizumab only (26 months total). Patient 7 with a massive neck tumor and lung metastasis had a PET/CT confirmed CR 12 months after starting treatment. He stopped lenvatinib after 15 months and now continues with pembrolizumab only (19 months total). ATC patient 5 had confirmed CR 10 months after treatment start, but unfortunately died due to bleeding complications after removal of the tracheostomy tube (Table 3 and Supplementary Table S2).
Treatment durations ranged from 1 to 40 months (ATC: 40, 26, 19, 18, 4, and 1 month; PDTC: 25 and 15 months, respectively), with three patients being treated for more than 2 years (Fig. 1D). At the time of data cutoff, 3 of 8 patients (patients 2, 4, and 7, all ATCs) were still alive and on therapy (40, 26, and 19 months). We stopped the treatment of patient 2 after 40 months of treatment, and he is now regularly monitored by CT scans every 3 months. The other patients died due to disease progression (2/6 ATC, 2/2 PDTC) or hemorrhage (grade IV SAE, patient 5, Table 3). ATC patient 8 was resistant to the treatment. ATC patients 1 and 6 died shortly after discontinuation of the lenvatinib treatment caused by lenvatinib intolerance in patient 6 (grade III anorexia), and because lenvatinib had to be discontinued due to an infectious complication after a knee surgery in patient 1 (Table 3). The median PFS for the total cohort was 17.6 months, and the median OS was 19 months (Fig. 2). Data analysis for ATC only showed a median PFS of 16.8 months and a median OS of 17.3 months (Fig. 2).
FIG. 2. Kaplan–Meier curves for ATCs only and total patients. (A) PFS in all patients and ATC only. (B) OS in all patients and ATC only. ATC, anaplastic thyroid carcinoma; OS, overall survival; PFS, progression-free survival.
Biomarkers
To assess potential predictors of treatment response, we investigated the PD-L1 expression of the tumor cells and macrophages/immune cells. Furthermore, WES was performed in 7 of 8 patients, and sequences were compared to germ line sequences to assess somatic mutations and the TMB. In 1 patient (1/8), targeted sequencing for 11 frequently mutated genes (Supplementary Table S1) was performed due to low material. All tumors were positive for PD-L1 expression with a TPS ranging from 1% to 90%, and 5 of 8 patients with TPS >50% (Table 4). The CPS ranged from 5 to 100 (Table 4). Interestingly, the ATC patient with the lowest TPS (1%) and CPS 5 did not respond to the treatment (patient 8). In contrast, the patients with responses lasting more than two years and those achieving a CR all had PD-L1 TPS >50% (5/8), a CPS >75 (3/8), or a high mutation frequency above 5 mutations per megabase (3/8). The patient (patient 2) with the highest number of mutations (>1400 somatic mutations) has the longest CR duration (30 months).
Table 4. Biomarker Analysis
Patient ORR after 3/4 months (RECIST 1.1) BOR (CT/MRI/PET-CT) Response according to PET-CT TPS, % CPS Somatic mutations TMB (mutations/Mb)
1 PR PR PR 50 40 106 13.79
2 PR CR CR 60 75 1447 81.87
3 PR PR PR 10 10 79 4.08
4 PR CR CR 90 100 19 3
5 PR CR n.a. 80 100 29 3.3
6 SD SD n.a. 60 65 24 3.58
7 PR CR CR 5 7 138 5.59
8 PD PD n.a. 1 5 n.a. n.a.
CPS, combined proportion score; MRI, magnet resonance tomography; n.a., not applicable; TMB, tumor mutation burden; TPS, tumor proportion score.
Discussion
Current treatment options for ATC are limited, and response rates are low and short-lived, with marginal to absent CR (13,14). Only the small proportion of BRAFV600E-mutated ATC (about 20%) can be effectively treated with a BRAF/MEK inhibitor combination of dabrafenib and trametinib (10,11), but for the other 70–80% of ATCs, no treatment options are approved after chemotherapy failure in most countries.
ATC and PDTC are characterized by a very high proliferation rate and tumor invasiveness, driven by concurrent mutations in several pro-proliferative pathways (RAS, WNT, loss of TP53), and strongly activated VEGF/FGF signaling. PD-L1 and TMB are upregulated, but the response to single immune checkpoint inhibition often comes too late and is overrun by the aggressiveness of the disease (36).
While many kinase inhibitors (sorafenib/pazopanib) failed to show treatment efficacy in ATC (30–32), lenvatinib trials demonstrated some promising effects, with 17.4–43% PRs and up to 50% SD (27–29). CRs were absent and PFS lasted only between 77 days and 7.4 months (27–29). Besides its fast, but short-lived antiproliferative effects, lenvatinib was shown to improve immune responses to immune checkpoint inhibitors in mice. Therefore, by combining both agents, we aimed to use lenvatinib as a fast and effective bridging treatment and immuno-sensitizer for the immune checkpoint inhibitor pembrolizumab in ATC/PDTC patients.
In contrast to single-agent therapy, the combination of lenvatinib and pembrolizumab was highly effective in our treatment cohort. Eight ATC/PDTC patients who had previously been treated with several lines of therapy including chemotherapy, chemoirradiation, and even single immune checkpoint inhibition (1/8) received a combination of lenvatinib and pembrolizumab for a maximum of 40 months. The combination treatment was well tolerated and could be sustained over one year in half of the patients, and even over two years in 37% (3/8) of the patients. Half of the ATC patients (3/6) were still on therapy at data cutoff with no sustained grade III/IV toxicities despite having initially metastatic disease; three patients had confirmed CR by PET/CT and/or histopathologic examination of former metastatic sites. Seventy-five percent of all patients and 66% of the ATC patients reached a PR/CR within 16 months of treatment. The remission rates observed with lenvatinib/pembrolizumab combination in ATC/PDTC are similar to previously published data for other heavily pretreated solid tumors, such as patients with head and neck tumors, endometrial, renal cell, or hepatocellular carcinoma (39–42). As CRs and long-lasting remissions were rarely observed in ATC patients treated with lenvatinib only (27–29), the addition of pembrolizumab is most likely inducing this effect.
In patients who are already resistant to TKI treatment, the addition of pembrolizumab is only partially functional with a PFS of only 2.96 months (43), which indicates that the up-front combination of lenvatinib and pembrolizumab might be much more effective than using these drugs sequentially.
TMB and PD-L1 expression levels (TPS/CPS) are independent biomarkers for response to immune checkpoint inhibitors in solid tumors (30,46,47). In our analysis, patients reaching a CR or those who had long-term remission over two years all had a TPS above 50%, a CPS higher than 75, and/or a TMB >5/MB, indicating that those may be biomarkers for response to lenvatinib/pembrolizumab treatment in ATC/PDTC.
In general, the combination of lenvatinib and pembrolizumab was well tolerated even in the elderly patients with a higher ECOG performance status. Results are encouraging with an ORR of 75%, including a CR rate of 50% (66% in ATCs) and responses over 2 years. Therefore, the treatment results and biomarkers will be further evaluated in a phase II clinical trial with lenvatinib and pembrolizumab in ATC/PDTC patients (ATLEP trial, Anaplastic Thyroid Carcinoma Lenvatinib Pembrolizumab, EudraCT No. 2017-004570-34).
Supplementary Material
Supplemental data
Supplemental data
Supplemental data
Supplemental data
Supplemental data
Acknowledgments
Thanks to our patients and relatives for their support for this study. Thanks to Prof. Roland Mertelsmann for his continuous support and wisdom. Thanks to the molecular tumor board and the CCCF for their support.
Authors' Contributions
C.D., J.S., C.M., O.T., H.W., and N.B. wrote the article. J.R., C.K., and P.T.M. performed and evaluated PET/CTs. K.A., and S.K. performed PD-L1 staining and evaluation. M.R. designed figures. M.B. and P.M. analyzed WES data. A.Z., P.R., M.K., C.W., T.S., C.S., C.M., C.K., N.B., and K.L. treated patients and revised the article.
Author Disclosure Statement
C.D. received honoraria and travel costs for consultancy role at Eisai, AbbVie, and Gilead. M.K. received honoraria and travel costs for consultancy role at Eisai GmbH. A.Z. received honoraria and travel costs for consultancy role at Eisai, J&J, and Merck and participates in the Keynote 158 trial.
Funding Information
Resarch funding grant for IIT trials from the University of Freiburg.
Supplementary Material
Supplementary Data
Supplementary Table S1
Supplementary Table S2
Supplementary Table S3
Supplementary Table S4 | CARBOPLATIN, PACLITAXEL | DrugsGivenReaction | CC BY | 33509020 | 20,554,496 | 2021-07 |
Give an alphabetized list of all active substances of drugs taken by the patient who experienced 'Thyroid cancer recurrent'. | Combination of Lenvatinib and Pembrolizumab Is an Effective Treatment Option for Anaplastic and Poorly Differentiated Thyroid Carcinoma.
Anaplastic thyroid carcinoma (ATC) and metastatic poorly differentiated thyroid carcinomas (PDTCs) are rare aggressive malignancies with poor overall survival (OS) despite extensive multimodal therapy. These tumors are highly proliferative, with frequently increased tumor mutational burden (TMB) compared with differentiated thyroid carcinomas, and elevated programmed death ligand 1 (PD-L1) levels. These tumor properties implicate responsiveness to antiangiogenic and antiproliferative multikinase inhibitors such as lenvatinib, and immune checkpoint inhibitors such as pembrolizumab. In a retrospective study, we analyzed six patients with metastatic ATC and two patients with PDTC, who received a combination therapy of lenvatinib and pembrolizumab. Lenvatinib was started at 14-24 mg daily and combined with pembrolizumab at a fixed dose of 200 mg every three weeks. Maximum treatment duration with this combination was 40 months, and 3 of 6 ATC patients are still on therapy. Patient tumors were characterized by whole-exome sequencing and PD-L1 expression levels (tumor proportion score [TPS] 1-90%). Best overall response (BOR) within ATCs was 66% complete remissions (4/6 CR), 16% stable disease (1/6 SD), and 16% progressive disease (1/6 PD). BOR within PDTCs was partial remission (PR 2/2). The median progression-free survival was 17.75 months for all patients, and 16.5 months for ATCs, with treatment durations ranging from 1 to 40 months (1, 4, 11, 15, 19, 25, 27, and 40 months). Grade III/IV toxicities developed in 4 of 8 patients, requiring dose reduction/discontinuation of lenvatinib. The median OS was 18.5 months, with three ATC patients being still alive without relapse (40, 27, and 19 months) despite metastatic disease at the time of treatment initiation (UICC and stage IVC). All patients with long-term (>2 years) or complete responses (CRs) had either increased TMB or a PD-L1 TPS >50%. Our results implicate that the combination of lenvatinib and pembrolizumab might be safe and effective in patients with ATC/PDTC and can result in complete and long-term remissions. The combination treatment is now being systematically examined in a phase II clinical trial (Anaplastic Thyroid Carcinoma Lenvatinib Pembrolizumab [ATLEP]) in ATC/PDTC patients.
Introduction
Anaplastic thyroid carcinoma (ATC) is a rare disease with an extremely high mortality rate and a 10-year survival below 5% (1). ATCs grow very fast, infiltrate into cervical structures, such as the esophagus, trachea, or blood vessels, and metastasize to the lung, brain, and bone. Even with extensive multimodal therapy (surgery, external beam radiotherapy, and chemotherapy), the median overall survival (OS) is only 3–5 months (1–3). ATC frequently arises from differentiated thyroid carcinoma (DTC) but can also emerge de novo. Typical molecular features of ATC are mutations in TP53 (54–64%), TERT (61%), KRAS/NRAS (28–43%), BRAF (18–28%), NF1, NF2, PI3K, PTEN, and genes in the WNT signaling pathway (4–9). BRAF/MEK inhibitor combinations (dabrafenib/trametinib) are approved for BRAFV600E-mutated ATCs and have significantly enhanced survival and has high treatment response (overall response rate [ORR] 69%) (10,11). All other locally advanced or metastatic ATCs (about 75%) are individually treated with carboplatin, paclitaxel, or doxorubicin containing chemotherapeutic regimens with very modest ORR (10–20%) lasting only for a few months (progression-free survival [PFS] 3–4 months) (12–15). Poorly differentiated thyroid carcinoma (PDTC) has a more favorable prognosis, with some patients being partially responsive to radioiodine therapy (RIT), but 10-year survival is also below 10%.
Compared with DTC, ATC/PDTC are characterized by an elevated tumor mutation burden, higher programmed death ligand 1 (PD-L1) levels, and increased neoangiogenesis (VEGFR/FGFR signaling) (7,16–22), suggesting that they may be sensitivity to immune checkpoint and neoangiogenesis inhibitors.
Lenvatinib is an antiangiogenic (VEGFR 1–3/FGFR 1–4) and antiproliferative (RET/PDGFR) tyrosine kinase inhibitor (TKI), which is approved for DTC refractory to radioiodine treatment (23). PFS in DTC is 19.4 months (23–26), but it is reduced to 14.8 months in PDTC, and all patients ultimately develop treatment resistance or treatment intolerance (26). In ATC, the PFS is even shorter (5.6–7.4 months) with variable ORR between 17.4% and 43%, depending on the initial tumor stage (27–29).
Pembrolizumab is an immune checkpoint inhibitor targeting PD-1 on immune cells. Response to pembrolizumab treatment is associated with elevated expression of PD-L1 or high tumor mutational burden (TMB) (30–34). DTC have low TMB and low PD-L1 expression (CPS/TPS) and hence have low response rates to immune checkpoint inhibitor treatments (ORR 9%) (35). In ATC with higher PD-L1/TMB, the effect of immune checkpoint inhibitors is still low (ORR <10%) (36,37), as the slow response to treatment (>8 weeks) cannot keep pace with the aggressive tumor growth.
In vitro studies and mouse experiments indicate synergism between lenvatinib and pembrolizumab (38). Lenvatinib not only blocks tumor neoangiogenesis and proliferation but also enhances immune cell invasion into the tumor and therefore fosters immune responses induced by immune checkpoint inhibitors (38). Furthermore, phase II trials with the lenvatinib/pembrolizumab combination in patients with extensively pretreated metastatic solid tumors (renal, ovarian, and endometrial carcinoma) not only showed acceptable toxicity but also very promising response rates (84% partial response [PR], 16% stable disease [SD]). Phase II/III trials for endometrial, head and neck, and hepatocellular carcinoma validated the high efficacy and safety for this combination (39–42). In ATC, pembrolizumab treatment was used as a salvage strategy after patients had failed lenvatinib or dabrafenib monotherapy or a dabrafenib/trametinib combination therapy. Pembrolizumab was added to the respective TKI and induced PR rates of 43%, but with a very short PFS of only 2.96 months (43).
In contrast to this study, we directly combined lenvatinib and pembrolizumab as front-line therapy after chemotherapy failure in eight patients with metastatic ATC (n = 6) or PDTC (n = 2) and examined treatment outcome and biomarkers for this approach.
Materials and Methods
Study population and patient characteristics
This is a retrospective, single-center (University Medical Center Freiburg) cohort study of eight patients with metastatic ATC (n = 6) or PDTC (n = 2) treated with a combination of the multikinase inhibitor lenvatinib and the immune checkpoint inhibitor pembrolizumab (L/P). Patient data were collected from March 2016 to December 2019 (Table 1). ATC/PDTC diagnosis was histopathologically confirmed by the Institute for Pathology, Freiburg, in all patients. Patients had no BRAFV600E mutation, but numerous other mutations were present (Supplementary Table S1). All patients were pretreated with irradiation, chemotherapy, or RIT (Table 1 and Supplementary Table S2). Adverse events (AEs) were reported according to the National Cancer Institute Common Terminology Criteria for Adverse Events (CTCAE version 5)–GBG (Table 2). The retrospective study was approved by the Institutional Review Board (IRB) of the University Freiburg.
Table 1. Baseline Characteristics
Median age at treatment start (range), years 63.5 (49–88)
Sex, n (%)
Men 4 (50)
Women 4 (50)
Performance status, n (%)
ECOG 0 3 (37.5)
ECOG 1 3 (37.5)
ECOG 2 2 (25)
Pathological diagnosis, n (%)
ATC 6 (75)
PDTC 2 (25)
Location of metastases, n (%)
Lung 8 (100)
Bone 2 (25)
Kidney 1 (12.5)
Brain 1 (12.5)
Liver 1 (12.5)
Skin 1 (12.5)
Cervical relapse, n (%) 6 (75)
Previous therapy, n (%)
Surgery 8 (100)
Radiation ± chemosensitizing 7 (87.5)
Chemotherapy 6 (75)
RIT 2 (25)
ATC, anaplastic thyroid carcinoma; ECOG, Eastern Cooperative Oncology Group; PDTC, poorly differentiated thyroid carcinoma; RIT, radioiodine therapy.
Table 2. Adverse Events According to the Common Terminology Criteria for Adverse Events Version 5.0
Event Grade I/II (%) Grade III/IV (%)
Total 8/8 (100) 3/8 (36)
Hypertension 5/8 (63)
Fatigue 2/8 (25) 1/8 (13)
Anorexia 2/8 (25) 2/8 (25)
Oral mucositis 2/8 (25)
Joint/muscle pain 1/8 (13)
Hand–foot syndrome 1/8 (13)
Diarrhea 1/8 (13)
Proteinuria 1/8 (13)
Abdominal pain 1/8 (13)
Cervical bleeding 1/8 (13)
Data are given as totals and %. Events reported are listed in descending frequency of columns for grade I/II and grade III/IV. A patients with several multiple occurrences of an adverse event is counted only once with the highest grade. A patient with multiple adverse events is counted only once in the total row.
Treatment strategy
Patients started with lenvatinib 24 mg oral daily if the body weight (BW) was more than 80 kg, or 20 mg for BW less than 80 kg. Pembrolizumab infusions were started in between 1 and 4 weeks after initiation of lenvatinib at a fixed dose of 200 mg total every 3 weeks. Dose for lenvatinib was stepwise reduced upon occurrence of side effects according to clinical judgment. Lenvatinib was given at least for 1 year and was then stopped in patients with confirmed complete response (CR). Pembrolizumab was given for up to 40 months. It will be continued in all patients reaching a CR for two more years.
Response assessment
Radiology assessment including cervical, chest, and abdominal computed tomography (CT) scans was performed before treatment and then every 3–4 months. Response to therapy was determined centrally using the RECIST 1.1 criteria (Fig. 1A and Supplementary Table S3). Positron emission tomography (PET)–CT using [18F] fluorodeoxyglucose (FDG) (PET/CT) was performed before treatment, and after 12–16 months of treatment to confirm CRs (the European Organisation for Research and Treatment of Cancer [EORTC] response criteria for PET). In case of persistent lesions without tracer uptake on PET/CT (PR according to the RECIST 1.1 [CT scan], but CR according to the EORTC criteria for PET), lesions were surgically removed (1/8) to confirm the absence of viable tumor tissue (pathological CR criteria, Supplementary Table S4).
FIG. 1. (A) ORR after 3–4 months of treatment, 6/8 PR, 1/8 SD, 1/8 PD. (B) BOR within 16 months of treatment. (C) Lenvatinib dosage and changes over time. (D) Treatment duration and ongoing treatment. Patients in CR. BOR, best overall response; CR, complete response; ORR, overall response rate; PD, progressive disease; PR, partial response; SD, stable disease.
The efficacy of the combination treatment was assessed by ORR 3–4 months after starting treatment, best overall response (BOR) (Fig. 1B), PFS, and OS. PFS was defined as the time elapsed between starting treatment and progression or death, whichever occurred first. OS was defined as the time between starting treatment and death.
Molecular testing and immunohistochemistry
Molecular testing by whole-exome sequencing (WES) was performed from formalin-fixed and paraffin-embedded tissue specimens at the Deutsches Krebsforschungszentrum Heidelberg (DKFZ) as described previously (44,45). PD-L1 status was determined by immunohistochemistry (antibody clone SP263; Ventana) in tumor tissue specimens obtained at initial diagnosis before treatment. The tumor proportion score (TPS) was determined as proportion of PD-L1-positive tumor cells of 100 tumor cells. The combined proportion score (CPS), as amount of PD-L1-positive tumor and immune cells within 100 tumor cells, was also determined centrally at the Department of Pathology of the University Medical Center Freiburg.
Statistical analysis
Kaplan–Meier curves were used for OS and PFS. Descriptive statistics were used to summarize patients' characteristics and AEs. Statistical analysis was performed using IBM SPSS Statistics version 25.
Results
Eight patients with metastatic ATC (n = 6) or PDTC (n = 2) were treated with a combination of lenvatinib and pembrolizumab after failing chemotherapy, irradiation, or RIT (Table 1 and Supplementary Table S2). All the 8 patients had been extensively pretreated with surgery (8/8), local cervical external beam radiation therapy (6/8), RIT (2/2), local cerebral irradiation therapy (1/8), or systemic chemotherapy alone (6/8) (carboplatin/paclitaxel [4/8], cisplatin/paclitaxel [1/8], cisplatin/doxorubicin [1/8], and paclitaxel only [1/8]) (Table 1 and Supplementary Table S2). The median patient age was 66.4 years. At the beginning of treatment with lenvatinib/pembrolizumab, all patients had stage IVC. All patients had lung metastasis (8/8), and 2 of 8 skeletal metastasis, 1 of 8 liver metastasis, 1 of 8 kidney metastasis, 1 of 8 skin metastasis, and 1 of 8 brain metastasis. Six of eight patients also had progression of their local tumor. Eastern Cooperative Oncology Group (ECOG) performance status ranged from 0 to 2, with 3 ECOG 0 (38%), 3 ECOG 1 (38%), and 2 ECOG 2 (25%). Molecular diagnostics showed that none of the patients had a BRAFV600E mutation, but numerous other mutations typical for ATC/PDTC were detected and are listed in Supplementary Table S1.
Treatment regimen and AEs
Lenvatinib was started at a daily dose of 24 mg in 5 of 8 patients (BW more than 80 kg) and 20 mg in 2 patients with bodyweight less than 80 kg. An 88-year-old woman started on 14 mg/day (Fig. 1C and Table 3). Pembrolizumab treatment was initiated after a median of 2.7 weeks (ranging from 1 to 4 weeks after starting lenvatinib) and was given i.v. at a fixed dose of 200 mg every 3 weeks. In general, the therapy was well tolerated with the predominant grade II to IV AEs (AEs according to the CTCAE) being hypertension (5/8), fatigue (4/8), weight loss/anorexia (3/8), oral mucositis (2/8), diarrhea (2/8), joint/muscle pain (1/8), and hand–foot syndrome (1/8) (Table 2). The lenvatinib dose was reduced stepwise upon occurrence of intolerable side effects from 24 to 20, 14, 12, and 10 mg/day (Fig. 1C). Most side effects resolved after reducing the dose of lenvatinib, but in two patients, lenvatinib-induced AEs required treatment discontinuation (patients 3 and 6, Table 3). One grade IV serious adverse event (SAE) with a lethal cervical bleeding occurred after removal of the tracheostomy in patient 5 despite being in complete remission (Tables 2 and 3).
Table 3. Patient History
Patient Entity Age, years Prior treatment ORR in 3/4 months BOR CT+PET PFS, months OS, months Adverse events (CTCAE in grade °) Median dose lenvatinib, mg/day Current therapy/ outcome
1 PDTC 63 S Rx C/T PR PR 25 27 Hypertension °II
Fatigue °II
Anorexia °I
Oral mucositis °I 24 PD/death after stopping lenvatinib due to a knee surgery
2 ATC 76 S Rx C/T PR CR 40 40 Hypertension °II
Anorexia °II 24 Alive, CR after 12 months lenvatinib/pembrolizumab, now without treatment
3 PDTC 49 S RIT C/T PR PR 15 23 Anorexia °III
Abdominal pain °III 14 PD/death, lenvatinib on/off due to weight loss/abdominal pain
4 ATC 68 S Rx C/T PR CR 26 26 Anorexia °I
Loss of appetite °II
Proteinuria °I
Hypertension °II 20 Alive, CR after 10 months of treatment, now pembrolizumab mono
5 ATC 63 S Rx C/T PR CR 11 11 Diarrhea °II
Hypertension °II
Cervical bleeding °IV 20 CR after 7 months of treatment. Death due to cervical bleeding
6 ATC 88 S Rx C/T SD SD 4 7 Diarrhea °II
Anorexia °III
Proteinuria °II
Fatigue °III
Oral mucositis °II 14 PD/death after stopping medication due to side effects
7 ATC 64 S RIT Rx PR CR 19 19 Hypertension °II
Fatigue °II
Joint pain °II
Hand–foot syndrome °I 24 Alive, CR, lenvatinib/pembrolizumab for 12 months, now pembrolizumab mono
8 ATC 60 S R C/T PD PD 1 1 Hypertension °II 24 PD/death due to cervical tumor progression
Patient characteristics including diagnosis, previous therapy (S, RIT, Rx, C/T), patient age, PFS, ORR, BOR, OS, response after 3 months, maximum response, main side effects, median dose lenvatinib in mg/day, dose pembrolizumab, current treatment/outcome. CTCAE grades in roman numbers. Responses were assessed via the RECIST v1.1 radiology assessment and FDG uptake according to the EORTC criteria for PET.
BOR, best overall response; C/T, chemotherapy; CT, computed tomography; CR, complete response; CTCAE, Common Terminology Criteria for Adverse Events; FDG, [18F] fluorodeoxyglucose; ORR, overall response rate; OS, overall survival; PD, progressive disease; PET, positron emission tomography; PFS, progression free survival; PR, partial response; Rx, radiation therapy; S, surgery; SD, stable disease.
After four months of treatment, lenvatinib/pembrolizumab was discontinued due to severe weight loss/anorexia (grade III) in the 88-year-old patient (patient 6), and she died due to disease progression three months later. One patient was intolerant to lenvatinib treatment due to grade III abdominal pain and weight loss/anorexia (patient 3). Lenvatinib was reduced from 24 to 20 to 14 and 12 mg/day in a stepwise manner, and after 14 months, lenvatinib/pembrolizumab treatment was discontinued. Two patients received the full dose of lenvatinib 24 mg for 24 months (Fig. 1C). Pembrolizumab was given for up to 40 months and will be continued in all patients reaching a CR for two more years (Fig. 1D).
Treatment efficacy
Treatment response was first assessed 3–4 months after lenvatinib/pembrolizumab treatment. Six of eight patients had a PR according to the RECIST v1.1 criteria (Fig. 1A). ORR for ATCs was 66% (4/6 PR). The 88-year-old patient (ATC) at 14 mg lenvatinib had SD (patient 6). One ATC patient (patient 8) did not respond to lenvatinib/pembrolizumab treatment combination and died within the first month of treatment due to cervical tumor progression (1/8 progressive disease) (Fig. 1A and Supplementary Data).
BOR changed in four ATC patients from PR to CR within 16 months of treatment (total CR rate 50%, CR rate for ATC 66%) (Fig. 1B). Individual patient history is summarized in the Supplementary Data. ATC patient 2 had a confirmed CR for all target- and nontarget lesions 16 months after lenvatinib/pembrolizumab treatment, and stopped taking lenvatinib after 2 years (24 mg daily for 24 months), but continued pembrolizumab for 16 more months (40 months total). He stopped treatment for 6 months and is still in CR. ATC patient 4 with lung and brain metastases had a PR 12 months after starting treatment, but all lesions in the lung were without FDG uptake (CR according to the EORTC criteria for PET). All lung lesions were surgically removed and showed a pathological CR (no viable tumor cells). Therefore, the patient was judged as having a CR and has discontinued lenvatinib after 1 year of treatment, and continues with pembrolizumab only (26 months total). Patient 7 with a massive neck tumor and lung metastasis had a PET/CT confirmed CR 12 months after starting treatment. He stopped lenvatinib after 15 months and now continues with pembrolizumab only (19 months total). ATC patient 5 had confirmed CR 10 months after treatment start, but unfortunately died due to bleeding complications after removal of the tracheostomy tube (Table 3 and Supplementary Table S2).
Treatment durations ranged from 1 to 40 months (ATC: 40, 26, 19, 18, 4, and 1 month; PDTC: 25 and 15 months, respectively), with three patients being treated for more than 2 years (Fig. 1D). At the time of data cutoff, 3 of 8 patients (patients 2, 4, and 7, all ATCs) were still alive and on therapy (40, 26, and 19 months). We stopped the treatment of patient 2 after 40 months of treatment, and he is now regularly monitored by CT scans every 3 months. The other patients died due to disease progression (2/6 ATC, 2/2 PDTC) or hemorrhage (grade IV SAE, patient 5, Table 3). ATC patient 8 was resistant to the treatment. ATC patients 1 and 6 died shortly after discontinuation of the lenvatinib treatment caused by lenvatinib intolerance in patient 6 (grade III anorexia), and because lenvatinib had to be discontinued due to an infectious complication after a knee surgery in patient 1 (Table 3). The median PFS for the total cohort was 17.6 months, and the median OS was 19 months (Fig. 2). Data analysis for ATC only showed a median PFS of 16.8 months and a median OS of 17.3 months (Fig. 2).
FIG. 2. Kaplan–Meier curves for ATCs only and total patients. (A) PFS in all patients and ATC only. (B) OS in all patients and ATC only. ATC, anaplastic thyroid carcinoma; OS, overall survival; PFS, progression-free survival.
Biomarkers
To assess potential predictors of treatment response, we investigated the PD-L1 expression of the tumor cells and macrophages/immune cells. Furthermore, WES was performed in 7 of 8 patients, and sequences were compared to germ line sequences to assess somatic mutations and the TMB. In 1 patient (1/8), targeted sequencing for 11 frequently mutated genes (Supplementary Table S1) was performed due to low material. All tumors were positive for PD-L1 expression with a TPS ranging from 1% to 90%, and 5 of 8 patients with TPS >50% (Table 4). The CPS ranged from 5 to 100 (Table 4). Interestingly, the ATC patient with the lowest TPS (1%) and CPS 5 did not respond to the treatment (patient 8). In contrast, the patients with responses lasting more than two years and those achieving a CR all had PD-L1 TPS >50% (5/8), a CPS >75 (3/8), or a high mutation frequency above 5 mutations per megabase (3/8). The patient (patient 2) with the highest number of mutations (>1400 somatic mutations) has the longest CR duration (30 months).
Table 4. Biomarker Analysis
Patient ORR after 3/4 months (RECIST 1.1) BOR (CT/MRI/PET-CT) Response according to PET-CT TPS, % CPS Somatic mutations TMB (mutations/Mb)
1 PR PR PR 50 40 106 13.79
2 PR CR CR 60 75 1447 81.87
3 PR PR PR 10 10 79 4.08
4 PR CR CR 90 100 19 3
5 PR CR n.a. 80 100 29 3.3
6 SD SD n.a. 60 65 24 3.58
7 PR CR CR 5 7 138 5.59
8 PD PD n.a. 1 5 n.a. n.a.
CPS, combined proportion score; MRI, magnet resonance tomography; n.a., not applicable; TMB, tumor mutation burden; TPS, tumor proportion score.
Discussion
Current treatment options for ATC are limited, and response rates are low and short-lived, with marginal to absent CR (13,14). Only the small proportion of BRAFV600E-mutated ATC (about 20%) can be effectively treated with a BRAF/MEK inhibitor combination of dabrafenib and trametinib (10,11), but for the other 70–80% of ATCs, no treatment options are approved after chemotherapy failure in most countries.
ATC and PDTC are characterized by a very high proliferation rate and tumor invasiveness, driven by concurrent mutations in several pro-proliferative pathways (RAS, WNT, loss of TP53), and strongly activated VEGF/FGF signaling. PD-L1 and TMB are upregulated, but the response to single immune checkpoint inhibition often comes too late and is overrun by the aggressiveness of the disease (36).
While many kinase inhibitors (sorafenib/pazopanib) failed to show treatment efficacy in ATC (30–32), lenvatinib trials demonstrated some promising effects, with 17.4–43% PRs and up to 50% SD (27–29). CRs were absent and PFS lasted only between 77 days and 7.4 months (27–29). Besides its fast, but short-lived antiproliferative effects, lenvatinib was shown to improve immune responses to immune checkpoint inhibitors in mice. Therefore, by combining both agents, we aimed to use lenvatinib as a fast and effective bridging treatment and immuno-sensitizer for the immune checkpoint inhibitor pembrolizumab in ATC/PDTC patients.
In contrast to single-agent therapy, the combination of lenvatinib and pembrolizumab was highly effective in our treatment cohort. Eight ATC/PDTC patients who had previously been treated with several lines of therapy including chemotherapy, chemoirradiation, and even single immune checkpoint inhibition (1/8) received a combination of lenvatinib and pembrolizumab for a maximum of 40 months. The combination treatment was well tolerated and could be sustained over one year in half of the patients, and even over two years in 37% (3/8) of the patients. Half of the ATC patients (3/6) were still on therapy at data cutoff with no sustained grade III/IV toxicities despite having initially metastatic disease; three patients had confirmed CR by PET/CT and/or histopathologic examination of former metastatic sites. Seventy-five percent of all patients and 66% of the ATC patients reached a PR/CR within 16 months of treatment. The remission rates observed with lenvatinib/pembrolizumab combination in ATC/PDTC are similar to previously published data for other heavily pretreated solid tumors, such as patients with head and neck tumors, endometrial, renal cell, or hepatocellular carcinoma (39–42). As CRs and long-lasting remissions were rarely observed in ATC patients treated with lenvatinib only (27–29), the addition of pembrolizumab is most likely inducing this effect.
In patients who are already resistant to TKI treatment, the addition of pembrolizumab is only partially functional with a PFS of only 2.96 months (43), which indicates that the up-front combination of lenvatinib and pembrolizumab might be much more effective than using these drugs sequentially.
TMB and PD-L1 expression levels (TPS/CPS) are independent biomarkers for response to immune checkpoint inhibitors in solid tumors (30,46,47). In our analysis, patients reaching a CR or those who had long-term remission over two years all had a TPS above 50%, a CPS higher than 75, and/or a TMB >5/MB, indicating that those may be biomarkers for response to lenvatinib/pembrolizumab treatment in ATC/PDTC.
In general, the combination of lenvatinib and pembrolizumab was well tolerated even in the elderly patients with a higher ECOG performance status. Results are encouraging with an ORR of 75%, including a CR rate of 50% (66% in ATCs) and responses over 2 years. Therefore, the treatment results and biomarkers will be further evaluated in a phase II clinical trial with lenvatinib and pembrolizumab in ATC/PDTC patients (ATLEP trial, Anaplastic Thyroid Carcinoma Lenvatinib Pembrolizumab, EudraCT No. 2017-004570-34).
Supplementary Material
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Acknowledgments
Thanks to our patients and relatives for their support for this study. Thanks to Prof. Roland Mertelsmann for his continuous support and wisdom. Thanks to the molecular tumor board and the CCCF for their support.
Authors' Contributions
C.D., J.S., C.M., O.T., H.W., and N.B. wrote the article. J.R., C.K., and P.T.M. performed and evaluated PET/CTs. K.A., and S.K. performed PD-L1 staining and evaluation. M.R. designed figures. M.B. and P.M. analyzed WES data. A.Z., P.R., M.K., C.W., T.S., C.S., C.M., C.K., N.B., and K.L. treated patients and revised the article.
Author Disclosure Statement
C.D. received honoraria and travel costs for consultancy role at Eisai, AbbVie, and Gilead. M.K. received honoraria and travel costs for consultancy role at Eisai GmbH. A.Z. received honoraria and travel costs for consultancy role at Eisai, J&J, and Merck and participates in the Keynote 158 trial.
Funding Information
Resarch funding grant for IIT trials from the University of Freiburg.
Supplementary Material
Supplementary Data
Supplementary Table S1
Supplementary Table S2
Supplementary Table S3
Supplementary Table S4 | CARBOPLATIN, PACLITAXEL | DrugsGivenReaction | CC BY | 33509020 | 20,543,320 | 2021-07 |
Give an alphabetized list of all active substances of drugs taken by the patient who experienced 'Aspergillus infection'. | Severe Candida glabrata pancolitis and fatal Aspergillus fumigatus pulmonary infection in the setting of bone marrow aplasia after CD19-directed CAR T-cell therapy - a case report.
BACKGROUND
Prolonged myelosuppression following CD19-directed CAR T-cell transfusion represents an important, yet underreported, adverse event. The resulting neutropenia and multifactorial immunosuppression can facilitate severe infectious complications.
METHODS
We describe the clinical course of a 59-year-old patient with relapsed/refractory DLBCL who received Axicabtagene-Ciloleucel (Axi-cel). The patient developed ASTCT grade I CRS and grade IV ICANS, necessitating admission to the neurological ICU and prolonged application of high-dose corticosteroids and other immunosuppressive agents. Importantly, neutropenia was profound (ANC < 100/μl), G-CSF-refractory, and prolonged, lasting more than 50 days. The patient developed severe septic shock 3 weeks after CAR transfusion while receiving anti-fungal prophylaxis with micafungin. His clinical status stabilized with broad anti-infective treatment and intensive supportive measures. An autologous stem cell backup was employed on day 46 to support hematopoietic recovery. Although the counts of the patient eventually started to recover, he developed an invasive pulmonary aspergillosis, which ultimately lead to respiratory failure and death. Postmortem examination revealed signs of Candida glabrata pancolitis.
CONCLUSIONS
This case highlights the increased risk for fatal infectious complications in patients who present with profound and prolonged cytopenia after CAR T-cell therapy. We describe a rare case of C. glabrata pancolitis associated with multifactorial immunosuppression. Although our patient succumbed to a fatal fungal infection, autologous stem cell boost was able to spur hematopoiesis and may represent an important therapeutic strategy for DLBCL patients with CAR T-cell associated bone marrow aplasia who have underwent prior stem cell harvest.
Background
When CD19-directed Chimeric Antigen Receptor (CAR) T-cell therapies were first introduced into the clinical setting, a set of distinctive side effects were observed, including Cytokine Release Syndrome (CRS) and immune effector cell-associated neurotoxicity syndrome (ICANS). As these treatments transition from large clinical trials to real-world implementation, new nuances of the side effect spectrum have emerged. This includes the observation that patients can present not only with grade 3–4 cytopenia (CTCAE v5.0), but also a syndrome of persistent cytopenia after CAR T-cell transfusion [1, 2]. Hematologic toxicity is common with one study demonstrating that neutropenia, thrombocytopenia and anemia occur in 94, 80 and 51% of patients respectively [3]. Risk factors for hematotoxicity include CRS grade, baseline cytopenia, and prior allogeneic stem cell transplantation within the last year [2, 3]. The fact that baseline hematopoietic reserve contributes to cytopenia in CAR T-cell patients may explain the variability in the incidence of hematoxicity in the real-world setting compared to the large registration trials, which set stringent hematologic exclusion criteria [4, 5]. The clinical utility of therapeutic rescue strategies that mitigate the risk of infectious complications secondary to long-term bone marrow (BM) aplasia, such as early autologous stem cell boost or Eltrombopag, remains unknown. Moreover, the relative paucity of reports concerning severe and life-threatening infections in the reported CD19-directed CAR T-cell trials necessitates the presentation of distinctive clinical courses that underline the risks of persistent cytopenia after CAR T-cell therapy in a real-world setting.
Case presentation
The 59-year-old male patient was initially diagnosed with stage IIIA follicular lymphoma in January 2018, which transformed to germinal center B-cell like DLBCL in October of the same year. Refractory to multiple cycles of Rituximab-based immunochemotherapy (Fig. 1a), the patient underwent leukapheresis for CAR T-cell therapy in April 2019. The patient experienced significant lymphoma progression during the manufacturing process of Axicabtagene ciloleucel (Axi-cel), manifesting itself in the form of malignant pleural effusions and progressive lymphadenopathy (Fig. 2a,c,e). In the six-week period between leukapheresis and lymphodepletion, the patient remained severely neutropenic after R-CHOP and developed possible invasive fungal disease (IFD) [6] (Fig. 3e) as well as E. coli septicemia secondary to a urinary tract infection. These infections were treated successfully with liposomal amphotericin B and piperacillin/tazobactam. Prior to lymphodepletion (D-5), the patient presented with an ECOG performance status of 1, intact renal and liver function, while observing residually depressed blood counts (WBC 1270/μl, ANC 700/μl, ALC 390/μl, Hemoglobin 7.2 g/dl, Platelets 20 G/l). BM histopathology showed a hypocellular marrow with no evidence of lymphoma infiltration. Analysis of lymphocyte subpopulations demonstrated severe B-cell aplasia and decreased absolute CD4+ (84/μl) and CD8+ (271/μl) counts. His anti-infective prophylaxis consisted of a combination of acyclovir, sulfamethoxazole/trimethoprim (TMP/SMZ), and posaconazole. The fludarabine/cyclophosphamide lympho-preparative regimen was applied on days − 5 to − 3 according to the provider’s protocol, followed by CAR T-cell transfusion on day 0.
Fig. 1 Overview of CAR T-cell mediated hematotoxicity and infectious complications. a Treatment course prior to CAR T-cell therapy. b Timeline of infectious complications during CAR T-cell treatment course. Positive microbiologic culture results are underlined. Bottom: Overview of utilized anti-infectives with the respective bars displaying the length of treatment. P/T = piperacillin/tazobactam, Ami = amikacin, Mero = meropenem, Vanco = vancomycin, Line = linezolid, Posa = posaconazole (p.o.), Mica = micafungin (i.v.), Amb = liposomal amphotericin B. The patient also received prophylactic acyclovir and sulfamethoxazole/trimethoprim (TMP/SMZ) during treatment. c Complete Blood Count (CBC) timeline. ANC (blue), platelet count (green), Hemoglobin (red). Transfusion events (green: platelet transfusion, red: pRBC transfusion) and G-CSF support (blue bar) are integrated in the curve. d Dynamics of Serum Inflammatory Markers. Infectious complications are superimposed above the graph. e Histopathologic analysis of BM biopsies demonstrating severe BM aplasia 1 month after CAR T-cell transfusion (Day 32, upper panel) and evidence of recovering hematopoiesis following autologous stem cell transfer (Autopsy, lower panel). Immunohistochemical staining for myeloperoxidase (= MPO) highlighting strong activation of myelopoiesis (right panel)
Fig. 2 Radiographic evidence of partial response to Axi-cel after 36 days. Contrast-enhanced CT abdomen (axial view) displaying pleural manifestations before (a) and after (b) CAR T-cell treatment. Involved paraaortic lymph nodes (red arrows) demonstrate an interval decrease in size (c-d, e-f). The inset of panel F depicts splenic hypodensities consistent with necrosis of tumor tissue secondary to immune therapy and a reduction of splenomegaly. G Graphical depiction of response over time. Tumor extent was quantified as the sum of the product of perpendicular diameters according to Lugano criteria over 3 time points and is graphed on the y-axis. H Timeline of LDH levels (U/l). The increase in LDH levels at day 25 correlated with the gastrointestinal toxicity and liver dysfunction
Fig. 3 Multi-organ toxicity secondary to CD19-directed CAR T-cell therapy. a Contrast-enhanced CT abdomen demonstrating a non-inflamed baseline state of GI mucosal tissue prior to CAR T therapy. b Panmural swelling of the sigma (left panel), ascending colon (middle panel), and stomach. c Non-pathologic CT of the brain. d Axial FLAIR-weighted (left), T1-weighted contrast-enhanced (middle), and diffusion-weighted (right) MRI displaying no evidence of cerebral edema, white matter lesions, diffusion restriction, microbleeds, meningeal enhancement or contrast enhancing lesions. e High-resolution CT thorax with bilateral fungal infiltrates observing the typical halo configuration 6 weeks prior to CAR T-cell transfusion. f On day − 3 the right-sided infiltrates have decreased in size. The left lung is collapsed due to malignant pleural effusion. g Lung parenchyma exhibiting an infiltration of non-dimorphic blastoconidial morphology consistent with Candida glabrata. h PAS staining of a lung specimen highlights septated hiphae and acute-angle branching, features consistent of with aspergillus infection
During lymphodepletion the patient developed an upper respiratory infection, presenting with a non-productive cough and a sputum culture positive for Bordetella bronchiseptica, which resolved clinically after antibiotic treatment with piperacillin/tazobactam. On day 7, the patient developed fever with a stable cardiopulmonary function and concomitant IL-6 rise (Fig. 1d), which was classified as CRS grade I according to ASTCT consensus grading [7] in the absence of positive blood cultures and other foci. Due to persistent fever refractory to antipyretic treatment, four total doses of tocilizumab (8 mg/kg) were applied over 36 h. Starting on day 9, the patient deteriorated neurologically with a depressed state of consciousness prompting the diagnosis of grade IV ICANS. The patient was transferred to the neurological ICU, and high-dose corticosteroids (methylprednisolone 1000 mg daily) were initiated. CSF-analysis displayed subtle pleocytosis, but revealed no signs of CNS infection (viral, bacterial and fungal) or meningeal involvement of the DLBCL. CT and MR imaging of the brain exhibited none of the pathological findings reported for ICANS [8] or CNS infection [9](Fig. 3c-d). After 5 days of high-dose methylprednisolone, the patient’s neurological status slowly improved, and corticosteroids could be tapered.
Partial response to Axicabtagene-Ciloleucel after 36 days according to Lugano criteria
While the patient’s initial clinical course was fraught with complications, CT staging performed at day 36 demonstrated a partial response to CAR T-cell therapy according to Lugano and Lyric criteria (Fig. 2a-g). This was particularly evident for the pleural manifestations of the underlying DLBCL, which was accompanied by an interval decrease in pleural effusions and subjective dyspnea (Fig. 2a-b). Multiple nodal sites including paraaortic (Fig. 2c-d) and parailiac lymph nodes (Fig. 2e-f) exhibited significant regression of tumor size (Fig. 2g). Moreover, the patient displayed splenic hypodensities consistent with either tumor tissue necrosis or infection-associated inflammatory changes (inset, Fig. 2f). These CT-morphologic findings were accompanied by a decrease of LDH levels (Fig. 2h).
Prolonged cytopenia lead to the development of severe neutropenic colitis and fatal fungal pneumonia
The patient presented with significant myelotoxicity and sustained transfusion dependency after CAR T-cell administration (Fig. 1c). The overall duration of profound neutropenia – defined as an ANC < 100/μl [10] – was 52 days. Because of the severity of ICANS, the clinicians chose to hold G-CSF during this time period due to concerns for risk of worsening toxicity [11].
While receiving broad anti-infectives (acyclovir, TMP/SMZ, posaconazole, meropenem), the patient developed breakthrough septic shock on day 24. He exhibited fever (39.5 °C), hypotension (70/30 mmHg), tachycardia (160/min), as well as lactic acidosis (lactate: 10.7 mmol/l). The patient was non-conversant, non-oriented, and was not able to localize symptoms. However, he had described epigastric tenderness and subtle changes in stool consistency and frequency on the previous day. As a result, abdominal CT imaging was obtained, which displayed severe pancolitis, as evidenced by pronounced mucosal thickening with edematous changes ranging from the ascending colon to the rectum (Fig. 3a-b). Labs were notable for an acute spike of serum inflammatory parameters (Il-6 > 500.000 pg/ml, CRP 5.7 mg/dl, Procalcitonin 11.2 ng/ml, Fig. 1d). Following ICU transfer, high-dose vasopressor support with norepinephrine was initiated together with volume resuscitation to maintain organ perfusion. Due to progressive loss of consciousness the patient was intubated and mechanically ventilated. To control the proinflammatory state, extracorporeal cytokine absorption (Cytosorb®) was performed, which resulted in a decrease of soluble inflammatory markers in the subsequent days. Arterial blood cultures were positive for vancomycin-resistant enterococci (VRE), and the antibiotic treatment was escalated to include linezolid along with meropenem (Fig. 1b). The ICU team transitioned antifungal prophylaxis from posaconazole to an echinocandine (micafungin 50 mg IV) due to ECG changes and concerns for drug interactions on day 24. Though he remained in critical condition, in the coming weeks his clinical condition stabilized and both the catecholamine rate and volume support could be reduced. To determine the origin of sustained myelosuppression, a bone marrow biopsy was obtained, which depicted a hypocellular marrow and severe aplasia affecting all hematopoietic lineages (Fig. 1e). On days 41 and 49, surveillance blood cultures were positive for Candida glabrata, a commensal fungal organism of human mucosal tissues [12] harboring an intrinsic azole resistance [13]. Susceptibility testing confirmed the azole-resistance of C. glabrata isolates. The antimycotic therapy was escalated from micafungin to liposomal amphotericin B. C. glabrata likely disseminated to the bloodstream secondary to the described gastrointestinal toxicity and was previously discovered on rectal swab (Fig. 1b) and fecal culture (day − 51).
Due to sustained neutropenia, BM aplasia and the availability of a suitable apheresis product, the CAR T-cell Taskforce proceeded with a stem cell boost of previously collected autologous CD34+ cells (3,1 × 106 cells) on day 46. The combination of a sudden rise in serum inflammatory markers and a strongly positive serum galactomannan (GM) assay on day 49 prompted diagnostic bronchoscopy, which revealed a diffuse infiltrate of alveolar and peri-bronchial tissue by Aspergillus fumigatus, consistent with fulminant invasive fungal pneumonia. Over the next week, the patient became increasingly hemodynamically unstable with poor peripheral oxygenation. Repeat bronchoscopy with bronchial lavage was positive for A. fumigatus and C. glabrata. After 50 days of G-CSF refractory aplasia, the autologous stem cells slowly engrafted leading to neutrophil recovery. However, this likely exacerbated the local inflammatory reaction in the lung, contributing to rapid deterioration of his respiratory status. Despite extensive supportive measures, the patient died on day 58 after CAR T-cell transfusion. Cause of death was confirmed by autopsy as invasive fungal pneumonia with multi-organ septic spread. Post-mortem examination revealed Candida spores in intestinal, colonic and rectal tissue. Of note, histopathologic BM analysis revealed signs of burgeoning hematopoietic regeneration (Fig. 1e).
Discussion and conclusions
Recent studies have shed light on the high incidence of prolonged and profound neutropenia after adoptive immunotherapy with CD19-specific CAR T-cells [1–3]. Clinical sequalae include severe infectious complications, which have emerged as the number one cause of long-term non-relapse mortality after CAR T-cell therapy [14]. In a seminal study, Hill and colleagues demonstrate that infectious complications are common with a cumulative incidence of 23% in the first 28 days after CAR T-cell transfusion and 14% between days 29–90. While bacterial infections were most common in the first month, viral infections – especially respiratory viruses – predominated after day 29, likely as a result of an impaired adaptive immune response due to B-cell aplasia [15]. Overall, most infections were mild to moderate and fatal infections were rare. Invasive mold infections were uncommon, ranging from 1 to 7% in CAR T-cell recipients [15–17]. In multivariate analyses, the use of systemic corticosteroids for the management of CRS or ICANS has emerged as a major risk factor of infection [18]. Certain inflammatory signatures – such as the “double peaks of IL-6” pattern observed in our patient – have been shown to confer an especially high risk of life-threatening infection [19].
This case highlights the combination of factors that precipitate a high risk of infectious complications in a CAR T-cell patient. First, the heavily pre-treated patient displayed B-cell aplasia and a diminished hematopoietic reserve (e.g. trilineage cytopenia) prior to lymphodepletion. Second, the patient developed classic complications of CAR T-cell therapy such as CRS and severe and prolonged ICANS, reflecting a pro-inflammatory state that represents an important risk factor for developing infections in CAR T-cell patients [16]. The subsequent application of high-dose corticosteroids impaired both innate and adaptive immunity [20]. Third, pancytopenia was profound, prolonged and not able to be reverted by growth factor support. Fourth, the patient had a history of infectious complications, including a course of fungal pneumonia 6 weeks prior to lymphodepletion, likely flaring up in the setting of the above three factors.
Our patient developed severe septic shock secondary to neutropenic colitis on day 24, highlighting the risk of a watch-and-wait approach to prolonged neutropenia after CAR T-cell therapy. A two-pronged approach to management appears prescient. On the one hand, measures to propagate hematopoietic recovery should be exhausted (causal therapy). This can range from G-CSF stimulation, to a trial of pulse-dose corticosteroids or anti-cytokine therapy (e.g. Anakinra, Tocilizumab), to a stem cell boost as a last resort in lymphoma patients who have undergone prior autologous stem cell transplantation. On the other hand, clinicians should be at high alert for infectious complications and adapt their infection surveillance and anti-infective prophylactic strategies accordingly. For example, therapeutic drug monitoring of posaconazole and meropenem levels may have revealed subtherapeutic dosing of these anti-infective agents in this patient [21]. The role of antifungal prophylaxis in the CAR T-cell patient remains inconclusive. Adequately powered studies addressing the duration of neutropenia after CAR T-cell therapy, and potential clinical determinants of invasive fungal infections, will be critical to gauge the benefit of antifungal prophylaxis in this patient collective.
Candida species are a leading cause of fungus-associated morbidity and mortality in severely immunocompromised patients [21]. On day 41, this patient developed breakthrough C. glabrata Candidemia on micafungin, in the setting of both underlying colonization and neutropenic colitis. A recent report implicated the gastrointestinal tract as major source of echinocandin drug resistance in a murine model of C. glabrata colonization and systemic dissemination [22]. Of note, breakthrough Candida infections on micafungin may occur at the employed dose level (50 mg/day IV), suggesting that this dose may have been inadequate to prevent subsequent Candidemia [23]. Though cases of C. glabrata colitis are extremely rare [24], an opportunistic infection could not be ruled out given that C. glabrata infiltrates were discovered in enteral and colonic mucosal tissue on post-mortem examination. Importantly, the patients’ clinical status deteriorated only after the stem cell boost resulted in signs of hematopoietic recovery. The paradoxical worsening of the pulmonary A. fumigatus infection is consistent with immune reconstitution inflammatory syndrome (IRIS), which has been previously described for HIV/AIDS [25] and for severely neutropenic patients with IPA [26]. In conclusion, this case emphasizes that infectious complications secondary to prolonged cytopenia influence non-relapse mortality after CAR T-cell therapy.
Abbreviations
ALCAbsolute Lymphocyte Count
ANCAbsolute Neutrophil Count
BMBone Marrow
CARChimeric antigen receptor
CBCComplete Blood Count
CRSCytokine release syndrome
CTCAECommon Terminology Criteria for Adverse Events
DLBCLDiffuse large B-cell lymphoma
FFPFresh frozen plasma
FLAIRFluid-attenuated inversion recovery
Flu/CyFludarabine/Cyclophosphamide
G-CSFGranulocyte colony stimulating factor
GIGastrointestinal
GMGalactomannan
HSPCsHematopoietic stem and progenitor cells
ICANSImmune effector cell-associated neurotoxicity syndrome
ICE-scoreImmune Effector Cell-associated Encephalopathy score
ICUIntensive care unit
IPAInvasive pulmonary aspergillosis
LDHLactate Dehydrogenase
LYRICLymphoma response to immunomodulatory therapy criteria
MDRDModification of Diet in Renal Disease
MPOMyeloperoxidase
PASPeriodic acid-Schiff
PBSCPeripheral Blood Stem Cell
VREVancomycin-resistant Enterococcus
WBCWhite Blood Count
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Acknowledgements
Not applicable.
Authors’ contributions
The original manuscript was written by KR. KR and WGK prepared the figures. MR performed the histological examination of the bone marrow. MS reviewed and edited the manuscript. The other authors (VB1, VB2, CS, PK, FS, KD, LvB, JS, OW, MD, MvBB) contributed to patient management and participated in drafting and editing the manuscript. All authors read and approved the final manuscript.
Funding
Not applicable. Open Access funding enabled and organized by Projekt DEAL.
Availability of data and materials
The authors did not use any database, software, or tools for the writing of this manuscript.
Ethics approval and consent to participate
The authors obtained consent from the deceased patient’s next-of-kin to participate.
Consent for publication
Written informed consent was obtained from the patient’s next-of-kin for publication of this Case report and any accompanying images. A copy of the written consent is available for review by the Editor of this journal.
Competing interests
The authors declare that they have no competing interests related with this case report. | CYCLOPHOSPHAMIDE, DOXORUBICIN HYDROCHLORIDE, METHYLPREDNISOLONE, PREDNISOLONE, RITUXIMAB, VINCRISTINE | DrugsGivenReaction | CC BY | 33509115 | 18,947,434 | 2021-01-28 |
Give an alphabetized list of all active substances of drugs taken by the patient who experienced 'Bordetella infection'. | Severe Candida glabrata pancolitis and fatal Aspergillus fumigatus pulmonary infection in the setting of bone marrow aplasia after CD19-directed CAR T-cell therapy - a case report.
BACKGROUND
Prolonged myelosuppression following CD19-directed CAR T-cell transfusion represents an important, yet underreported, adverse event. The resulting neutropenia and multifactorial immunosuppression can facilitate severe infectious complications.
METHODS
We describe the clinical course of a 59-year-old patient with relapsed/refractory DLBCL who received Axicabtagene-Ciloleucel (Axi-cel). The patient developed ASTCT grade I CRS and grade IV ICANS, necessitating admission to the neurological ICU and prolonged application of high-dose corticosteroids and other immunosuppressive agents. Importantly, neutropenia was profound (ANC < 100/μl), G-CSF-refractory, and prolonged, lasting more than 50 days. The patient developed severe septic shock 3 weeks after CAR transfusion while receiving anti-fungal prophylaxis with micafungin. His clinical status stabilized with broad anti-infective treatment and intensive supportive measures. An autologous stem cell backup was employed on day 46 to support hematopoietic recovery. Although the counts of the patient eventually started to recover, he developed an invasive pulmonary aspergillosis, which ultimately lead to respiratory failure and death. Postmortem examination revealed signs of Candida glabrata pancolitis.
CONCLUSIONS
This case highlights the increased risk for fatal infectious complications in patients who present with profound and prolonged cytopenia after CAR T-cell therapy. We describe a rare case of C. glabrata pancolitis associated with multifactorial immunosuppression. Although our patient succumbed to a fatal fungal infection, autologous stem cell boost was able to spur hematopoiesis and may represent an important therapeutic strategy for DLBCL patients with CAR T-cell associated bone marrow aplasia who have underwent prior stem cell harvest.
Background
When CD19-directed Chimeric Antigen Receptor (CAR) T-cell therapies were first introduced into the clinical setting, a set of distinctive side effects were observed, including Cytokine Release Syndrome (CRS) and immune effector cell-associated neurotoxicity syndrome (ICANS). As these treatments transition from large clinical trials to real-world implementation, new nuances of the side effect spectrum have emerged. This includes the observation that patients can present not only with grade 3–4 cytopenia (CTCAE v5.0), but also a syndrome of persistent cytopenia after CAR T-cell transfusion [1, 2]. Hematologic toxicity is common with one study demonstrating that neutropenia, thrombocytopenia and anemia occur in 94, 80 and 51% of patients respectively [3]. Risk factors for hematotoxicity include CRS grade, baseline cytopenia, and prior allogeneic stem cell transplantation within the last year [2, 3]. The fact that baseline hematopoietic reserve contributes to cytopenia in CAR T-cell patients may explain the variability in the incidence of hematoxicity in the real-world setting compared to the large registration trials, which set stringent hematologic exclusion criteria [4, 5]. The clinical utility of therapeutic rescue strategies that mitigate the risk of infectious complications secondary to long-term bone marrow (BM) aplasia, such as early autologous stem cell boost or Eltrombopag, remains unknown. Moreover, the relative paucity of reports concerning severe and life-threatening infections in the reported CD19-directed CAR T-cell trials necessitates the presentation of distinctive clinical courses that underline the risks of persistent cytopenia after CAR T-cell therapy in a real-world setting.
Case presentation
The 59-year-old male patient was initially diagnosed with stage IIIA follicular lymphoma in January 2018, which transformed to germinal center B-cell like DLBCL in October of the same year. Refractory to multiple cycles of Rituximab-based immunochemotherapy (Fig. 1a), the patient underwent leukapheresis for CAR T-cell therapy in April 2019. The patient experienced significant lymphoma progression during the manufacturing process of Axicabtagene ciloleucel (Axi-cel), manifesting itself in the form of malignant pleural effusions and progressive lymphadenopathy (Fig. 2a,c,e). In the six-week period between leukapheresis and lymphodepletion, the patient remained severely neutropenic after R-CHOP and developed possible invasive fungal disease (IFD) [6] (Fig. 3e) as well as E. coli septicemia secondary to a urinary tract infection. These infections were treated successfully with liposomal amphotericin B and piperacillin/tazobactam. Prior to lymphodepletion (D-5), the patient presented with an ECOG performance status of 1, intact renal and liver function, while observing residually depressed blood counts (WBC 1270/μl, ANC 700/μl, ALC 390/μl, Hemoglobin 7.2 g/dl, Platelets 20 G/l). BM histopathology showed a hypocellular marrow with no evidence of lymphoma infiltration. Analysis of lymphocyte subpopulations demonstrated severe B-cell aplasia and decreased absolute CD4+ (84/μl) and CD8+ (271/μl) counts. His anti-infective prophylaxis consisted of a combination of acyclovir, sulfamethoxazole/trimethoprim (TMP/SMZ), and posaconazole. The fludarabine/cyclophosphamide lympho-preparative regimen was applied on days − 5 to − 3 according to the provider’s protocol, followed by CAR T-cell transfusion on day 0.
Fig. 1 Overview of CAR T-cell mediated hematotoxicity and infectious complications. a Treatment course prior to CAR T-cell therapy. b Timeline of infectious complications during CAR T-cell treatment course. Positive microbiologic culture results are underlined. Bottom: Overview of utilized anti-infectives with the respective bars displaying the length of treatment. P/T = piperacillin/tazobactam, Ami = amikacin, Mero = meropenem, Vanco = vancomycin, Line = linezolid, Posa = posaconazole (p.o.), Mica = micafungin (i.v.), Amb = liposomal amphotericin B. The patient also received prophylactic acyclovir and sulfamethoxazole/trimethoprim (TMP/SMZ) during treatment. c Complete Blood Count (CBC) timeline. ANC (blue), platelet count (green), Hemoglobin (red). Transfusion events (green: platelet transfusion, red: pRBC transfusion) and G-CSF support (blue bar) are integrated in the curve. d Dynamics of Serum Inflammatory Markers. Infectious complications are superimposed above the graph. e Histopathologic analysis of BM biopsies demonstrating severe BM aplasia 1 month after CAR T-cell transfusion (Day 32, upper panel) and evidence of recovering hematopoiesis following autologous stem cell transfer (Autopsy, lower panel). Immunohistochemical staining for myeloperoxidase (= MPO) highlighting strong activation of myelopoiesis (right panel)
Fig. 2 Radiographic evidence of partial response to Axi-cel after 36 days. Contrast-enhanced CT abdomen (axial view) displaying pleural manifestations before (a) and after (b) CAR T-cell treatment. Involved paraaortic lymph nodes (red arrows) demonstrate an interval decrease in size (c-d, e-f). The inset of panel F depicts splenic hypodensities consistent with necrosis of tumor tissue secondary to immune therapy and a reduction of splenomegaly. G Graphical depiction of response over time. Tumor extent was quantified as the sum of the product of perpendicular diameters according to Lugano criteria over 3 time points and is graphed on the y-axis. H Timeline of LDH levels (U/l). The increase in LDH levels at day 25 correlated with the gastrointestinal toxicity and liver dysfunction
Fig. 3 Multi-organ toxicity secondary to CD19-directed CAR T-cell therapy. a Contrast-enhanced CT abdomen demonstrating a non-inflamed baseline state of GI mucosal tissue prior to CAR T therapy. b Panmural swelling of the sigma (left panel), ascending colon (middle panel), and stomach. c Non-pathologic CT of the brain. d Axial FLAIR-weighted (left), T1-weighted contrast-enhanced (middle), and diffusion-weighted (right) MRI displaying no evidence of cerebral edema, white matter lesions, diffusion restriction, microbleeds, meningeal enhancement or contrast enhancing lesions. e High-resolution CT thorax with bilateral fungal infiltrates observing the typical halo configuration 6 weeks prior to CAR T-cell transfusion. f On day − 3 the right-sided infiltrates have decreased in size. The left lung is collapsed due to malignant pleural effusion. g Lung parenchyma exhibiting an infiltration of non-dimorphic blastoconidial morphology consistent with Candida glabrata. h PAS staining of a lung specimen highlights septated hiphae and acute-angle branching, features consistent of with aspergillus infection
During lymphodepletion the patient developed an upper respiratory infection, presenting with a non-productive cough and a sputum culture positive for Bordetella bronchiseptica, which resolved clinically after antibiotic treatment with piperacillin/tazobactam. On day 7, the patient developed fever with a stable cardiopulmonary function and concomitant IL-6 rise (Fig. 1d), which was classified as CRS grade I according to ASTCT consensus grading [7] in the absence of positive blood cultures and other foci. Due to persistent fever refractory to antipyretic treatment, four total doses of tocilizumab (8 mg/kg) were applied over 36 h. Starting on day 9, the patient deteriorated neurologically with a depressed state of consciousness prompting the diagnosis of grade IV ICANS. The patient was transferred to the neurological ICU, and high-dose corticosteroids (methylprednisolone 1000 mg daily) were initiated. CSF-analysis displayed subtle pleocytosis, but revealed no signs of CNS infection (viral, bacterial and fungal) or meningeal involvement of the DLBCL. CT and MR imaging of the brain exhibited none of the pathological findings reported for ICANS [8] or CNS infection [9](Fig. 3c-d). After 5 days of high-dose methylprednisolone, the patient’s neurological status slowly improved, and corticosteroids could be tapered.
Partial response to Axicabtagene-Ciloleucel after 36 days according to Lugano criteria
While the patient’s initial clinical course was fraught with complications, CT staging performed at day 36 demonstrated a partial response to CAR T-cell therapy according to Lugano and Lyric criteria (Fig. 2a-g). This was particularly evident for the pleural manifestations of the underlying DLBCL, which was accompanied by an interval decrease in pleural effusions and subjective dyspnea (Fig. 2a-b). Multiple nodal sites including paraaortic (Fig. 2c-d) and parailiac lymph nodes (Fig. 2e-f) exhibited significant regression of tumor size (Fig. 2g). Moreover, the patient displayed splenic hypodensities consistent with either tumor tissue necrosis or infection-associated inflammatory changes (inset, Fig. 2f). These CT-morphologic findings were accompanied by a decrease of LDH levels (Fig. 2h).
Prolonged cytopenia lead to the development of severe neutropenic colitis and fatal fungal pneumonia
The patient presented with significant myelotoxicity and sustained transfusion dependency after CAR T-cell administration (Fig. 1c). The overall duration of profound neutropenia – defined as an ANC < 100/μl [10] – was 52 days. Because of the severity of ICANS, the clinicians chose to hold G-CSF during this time period due to concerns for risk of worsening toxicity [11].
While receiving broad anti-infectives (acyclovir, TMP/SMZ, posaconazole, meropenem), the patient developed breakthrough septic shock on day 24. He exhibited fever (39.5 °C), hypotension (70/30 mmHg), tachycardia (160/min), as well as lactic acidosis (lactate: 10.7 mmol/l). The patient was non-conversant, non-oriented, and was not able to localize symptoms. However, he had described epigastric tenderness and subtle changes in stool consistency and frequency on the previous day. As a result, abdominal CT imaging was obtained, which displayed severe pancolitis, as evidenced by pronounced mucosal thickening with edematous changes ranging from the ascending colon to the rectum (Fig. 3a-b). Labs were notable for an acute spike of serum inflammatory parameters (Il-6 > 500.000 pg/ml, CRP 5.7 mg/dl, Procalcitonin 11.2 ng/ml, Fig. 1d). Following ICU transfer, high-dose vasopressor support with norepinephrine was initiated together with volume resuscitation to maintain organ perfusion. Due to progressive loss of consciousness the patient was intubated and mechanically ventilated. To control the proinflammatory state, extracorporeal cytokine absorption (Cytosorb®) was performed, which resulted in a decrease of soluble inflammatory markers in the subsequent days. Arterial blood cultures were positive for vancomycin-resistant enterococci (VRE), and the antibiotic treatment was escalated to include linezolid along with meropenem (Fig. 1b). The ICU team transitioned antifungal prophylaxis from posaconazole to an echinocandine (micafungin 50 mg IV) due to ECG changes and concerns for drug interactions on day 24. Though he remained in critical condition, in the coming weeks his clinical condition stabilized and both the catecholamine rate and volume support could be reduced. To determine the origin of sustained myelosuppression, a bone marrow biopsy was obtained, which depicted a hypocellular marrow and severe aplasia affecting all hematopoietic lineages (Fig. 1e). On days 41 and 49, surveillance blood cultures were positive for Candida glabrata, a commensal fungal organism of human mucosal tissues [12] harboring an intrinsic azole resistance [13]. Susceptibility testing confirmed the azole-resistance of C. glabrata isolates. The antimycotic therapy was escalated from micafungin to liposomal amphotericin B. C. glabrata likely disseminated to the bloodstream secondary to the described gastrointestinal toxicity and was previously discovered on rectal swab (Fig. 1b) and fecal culture (day − 51).
Due to sustained neutropenia, BM aplasia and the availability of a suitable apheresis product, the CAR T-cell Taskforce proceeded with a stem cell boost of previously collected autologous CD34+ cells (3,1 × 106 cells) on day 46. The combination of a sudden rise in serum inflammatory markers and a strongly positive serum galactomannan (GM) assay on day 49 prompted diagnostic bronchoscopy, which revealed a diffuse infiltrate of alveolar and peri-bronchial tissue by Aspergillus fumigatus, consistent with fulminant invasive fungal pneumonia. Over the next week, the patient became increasingly hemodynamically unstable with poor peripheral oxygenation. Repeat bronchoscopy with bronchial lavage was positive for A. fumigatus and C. glabrata. After 50 days of G-CSF refractory aplasia, the autologous stem cells slowly engrafted leading to neutrophil recovery. However, this likely exacerbated the local inflammatory reaction in the lung, contributing to rapid deterioration of his respiratory status. Despite extensive supportive measures, the patient died on day 58 after CAR T-cell transfusion. Cause of death was confirmed by autopsy as invasive fungal pneumonia with multi-organ septic spread. Post-mortem examination revealed Candida spores in intestinal, colonic and rectal tissue. Of note, histopathologic BM analysis revealed signs of burgeoning hematopoietic regeneration (Fig. 1e).
Discussion and conclusions
Recent studies have shed light on the high incidence of prolonged and profound neutropenia after adoptive immunotherapy with CD19-specific CAR T-cells [1–3]. Clinical sequalae include severe infectious complications, which have emerged as the number one cause of long-term non-relapse mortality after CAR T-cell therapy [14]. In a seminal study, Hill and colleagues demonstrate that infectious complications are common with a cumulative incidence of 23% in the first 28 days after CAR T-cell transfusion and 14% between days 29–90. While bacterial infections were most common in the first month, viral infections – especially respiratory viruses – predominated after day 29, likely as a result of an impaired adaptive immune response due to B-cell aplasia [15]. Overall, most infections were mild to moderate and fatal infections were rare. Invasive mold infections were uncommon, ranging from 1 to 7% in CAR T-cell recipients [15–17]. In multivariate analyses, the use of systemic corticosteroids for the management of CRS or ICANS has emerged as a major risk factor of infection [18]. Certain inflammatory signatures – such as the “double peaks of IL-6” pattern observed in our patient – have been shown to confer an especially high risk of life-threatening infection [19].
This case highlights the combination of factors that precipitate a high risk of infectious complications in a CAR T-cell patient. First, the heavily pre-treated patient displayed B-cell aplasia and a diminished hematopoietic reserve (e.g. trilineage cytopenia) prior to lymphodepletion. Second, the patient developed classic complications of CAR T-cell therapy such as CRS and severe and prolonged ICANS, reflecting a pro-inflammatory state that represents an important risk factor for developing infections in CAR T-cell patients [16]. The subsequent application of high-dose corticosteroids impaired both innate and adaptive immunity [20]. Third, pancytopenia was profound, prolonged and not able to be reverted by growth factor support. Fourth, the patient had a history of infectious complications, including a course of fungal pneumonia 6 weeks prior to lymphodepletion, likely flaring up in the setting of the above three factors.
Our patient developed severe septic shock secondary to neutropenic colitis on day 24, highlighting the risk of a watch-and-wait approach to prolonged neutropenia after CAR T-cell therapy. A two-pronged approach to management appears prescient. On the one hand, measures to propagate hematopoietic recovery should be exhausted (causal therapy). This can range from G-CSF stimulation, to a trial of pulse-dose corticosteroids or anti-cytokine therapy (e.g. Anakinra, Tocilizumab), to a stem cell boost as a last resort in lymphoma patients who have undergone prior autologous stem cell transplantation. On the other hand, clinicians should be at high alert for infectious complications and adapt their infection surveillance and anti-infective prophylactic strategies accordingly. For example, therapeutic drug monitoring of posaconazole and meropenem levels may have revealed subtherapeutic dosing of these anti-infective agents in this patient [21]. The role of antifungal prophylaxis in the CAR T-cell patient remains inconclusive. Adequately powered studies addressing the duration of neutropenia after CAR T-cell therapy, and potential clinical determinants of invasive fungal infections, will be critical to gauge the benefit of antifungal prophylaxis in this patient collective.
Candida species are a leading cause of fungus-associated morbidity and mortality in severely immunocompromised patients [21]. On day 41, this patient developed breakthrough C. glabrata Candidemia on micafungin, in the setting of both underlying colonization and neutropenic colitis. A recent report implicated the gastrointestinal tract as major source of echinocandin drug resistance in a murine model of C. glabrata colonization and systemic dissemination [22]. Of note, breakthrough Candida infections on micafungin may occur at the employed dose level (50 mg/day IV), suggesting that this dose may have been inadequate to prevent subsequent Candidemia [23]. Though cases of C. glabrata colitis are extremely rare [24], an opportunistic infection could not be ruled out given that C. glabrata infiltrates were discovered in enteral and colonic mucosal tissue on post-mortem examination. Importantly, the patients’ clinical status deteriorated only after the stem cell boost resulted in signs of hematopoietic recovery. The paradoxical worsening of the pulmonary A. fumigatus infection is consistent with immune reconstitution inflammatory syndrome (IRIS), which has been previously described for HIV/AIDS [25] and for severely neutropenic patients with IPA [26]. In conclusion, this case emphasizes that infectious complications secondary to prolonged cytopenia influence non-relapse mortality after CAR T-cell therapy.
Abbreviations
ALCAbsolute Lymphocyte Count
ANCAbsolute Neutrophil Count
BMBone Marrow
CARChimeric antigen receptor
CBCComplete Blood Count
CRSCytokine release syndrome
CTCAECommon Terminology Criteria for Adverse Events
DLBCLDiffuse large B-cell lymphoma
FFPFresh frozen plasma
FLAIRFluid-attenuated inversion recovery
Flu/CyFludarabine/Cyclophosphamide
G-CSFGranulocyte colony stimulating factor
GIGastrointestinal
GMGalactomannan
HSPCsHematopoietic stem and progenitor cells
ICANSImmune effector cell-associated neurotoxicity syndrome
ICE-scoreImmune Effector Cell-associated Encephalopathy score
ICUIntensive care unit
IPAInvasive pulmonary aspergillosis
LDHLactate Dehydrogenase
LYRICLymphoma response to immunomodulatory therapy criteria
MDRDModification of Diet in Renal Disease
MPOMyeloperoxidase
PASPeriodic acid-Schiff
PBSCPeripheral Blood Stem Cell
VREVancomycin-resistant Enterococcus
WBCWhite Blood Count
Publisher’s Note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
Acknowledgements
Not applicable.
Authors’ contributions
The original manuscript was written by KR. KR and WGK prepared the figures. MR performed the histological examination of the bone marrow. MS reviewed and edited the manuscript. The other authors (VB1, VB2, CS, PK, FS, KD, LvB, JS, OW, MD, MvBB) contributed to patient management and participated in drafting and editing the manuscript. All authors read and approved the final manuscript.
Funding
Not applicable. Open Access funding enabled and organized by Projekt DEAL.
Availability of data and materials
The authors did not use any database, software, or tools for the writing of this manuscript.
Ethics approval and consent to participate
The authors obtained consent from the deceased patient’s next-of-kin to participate.
Consent for publication
Written informed consent was obtained from the patient’s next-of-kin for publication of this Case report and any accompanying images. A copy of the written consent is available for review by the Editor of this journal.
Competing interests
The authors declare that they have no competing interests related with this case report. | CYCLOPHOSPHAMIDE, DOXORUBICIN HYDROCHLORIDE, METHYLPREDNISOLONE, PREDNISOLONE, RITUXIMAB, VINCRISTINE | DrugsGivenReaction | CC BY | 33509115 | 18,947,434 | 2021-01-28 |
Give an alphabetized list of all active substances of drugs taken by the patient who experienced 'Bronchopulmonary aspergillosis'. | Severe Candida glabrata pancolitis and fatal Aspergillus fumigatus pulmonary infection in the setting of bone marrow aplasia after CD19-directed CAR T-cell therapy - a case report.
BACKGROUND
Prolonged myelosuppression following CD19-directed CAR T-cell transfusion represents an important, yet underreported, adverse event. The resulting neutropenia and multifactorial immunosuppression can facilitate severe infectious complications.
METHODS
We describe the clinical course of a 59-year-old patient with relapsed/refractory DLBCL who received Axicabtagene-Ciloleucel (Axi-cel). The patient developed ASTCT grade I CRS and grade IV ICANS, necessitating admission to the neurological ICU and prolonged application of high-dose corticosteroids and other immunosuppressive agents. Importantly, neutropenia was profound (ANC < 100/μl), G-CSF-refractory, and prolonged, lasting more than 50 days. The patient developed severe septic shock 3 weeks after CAR transfusion while receiving anti-fungal prophylaxis with micafungin. His clinical status stabilized with broad anti-infective treatment and intensive supportive measures. An autologous stem cell backup was employed on day 46 to support hematopoietic recovery. Although the counts of the patient eventually started to recover, he developed an invasive pulmonary aspergillosis, which ultimately lead to respiratory failure and death. Postmortem examination revealed signs of Candida glabrata pancolitis.
CONCLUSIONS
This case highlights the increased risk for fatal infectious complications in patients who present with profound and prolonged cytopenia after CAR T-cell therapy. We describe a rare case of C. glabrata pancolitis associated with multifactorial immunosuppression. Although our patient succumbed to a fatal fungal infection, autologous stem cell boost was able to spur hematopoiesis and may represent an important therapeutic strategy for DLBCL patients with CAR T-cell associated bone marrow aplasia who have underwent prior stem cell harvest.
Background
When CD19-directed Chimeric Antigen Receptor (CAR) T-cell therapies were first introduced into the clinical setting, a set of distinctive side effects were observed, including Cytokine Release Syndrome (CRS) and immune effector cell-associated neurotoxicity syndrome (ICANS). As these treatments transition from large clinical trials to real-world implementation, new nuances of the side effect spectrum have emerged. This includes the observation that patients can present not only with grade 3–4 cytopenia (CTCAE v5.0), but also a syndrome of persistent cytopenia after CAR T-cell transfusion [1, 2]. Hematologic toxicity is common with one study demonstrating that neutropenia, thrombocytopenia and anemia occur in 94, 80 and 51% of patients respectively [3]. Risk factors for hematotoxicity include CRS grade, baseline cytopenia, and prior allogeneic stem cell transplantation within the last year [2, 3]. The fact that baseline hematopoietic reserve contributes to cytopenia in CAR T-cell patients may explain the variability in the incidence of hematoxicity in the real-world setting compared to the large registration trials, which set stringent hematologic exclusion criteria [4, 5]. The clinical utility of therapeutic rescue strategies that mitigate the risk of infectious complications secondary to long-term bone marrow (BM) aplasia, such as early autologous stem cell boost or Eltrombopag, remains unknown. Moreover, the relative paucity of reports concerning severe and life-threatening infections in the reported CD19-directed CAR T-cell trials necessitates the presentation of distinctive clinical courses that underline the risks of persistent cytopenia after CAR T-cell therapy in a real-world setting.
Case presentation
The 59-year-old male patient was initially diagnosed with stage IIIA follicular lymphoma in January 2018, which transformed to germinal center B-cell like DLBCL in October of the same year. Refractory to multiple cycles of Rituximab-based immunochemotherapy (Fig. 1a), the patient underwent leukapheresis for CAR T-cell therapy in April 2019. The patient experienced significant lymphoma progression during the manufacturing process of Axicabtagene ciloleucel (Axi-cel), manifesting itself in the form of malignant pleural effusions and progressive lymphadenopathy (Fig. 2a,c,e). In the six-week period between leukapheresis and lymphodepletion, the patient remained severely neutropenic after R-CHOP and developed possible invasive fungal disease (IFD) [6] (Fig. 3e) as well as E. coli septicemia secondary to a urinary tract infection. These infections were treated successfully with liposomal amphotericin B and piperacillin/tazobactam. Prior to lymphodepletion (D-5), the patient presented with an ECOG performance status of 1, intact renal and liver function, while observing residually depressed blood counts (WBC 1270/μl, ANC 700/μl, ALC 390/μl, Hemoglobin 7.2 g/dl, Platelets 20 G/l). BM histopathology showed a hypocellular marrow with no evidence of lymphoma infiltration. Analysis of lymphocyte subpopulations demonstrated severe B-cell aplasia and decreased absolute CD4+ (84/μl) and CD8+ (271/μl) counts. His anti-infective prophylaxis consisted of a combination of acyclovir, sulfamethoxazole/trimethoprim (TMP/SMZ), and posaconazole. The fludarabine/cyclophosphamide lympho-preparative regimen was applied on days − 5 to − 3 according to the provider’s protocol, followed by CAR T-cell transfusion on day 0.
Fig. 1 Overview of CAR T-cell mediated hematotoxicity and infectious complications. a Treatment course prior to CAR T-cell therapy. b Timeline of infectious complications during CAR T-cell treatment course. Positive microbiologic culture results are underlined. Bottom: Overview of utilized anti-infectives with the respective bars displaying the length of treatment. P/T = piperacillin/tazobactam, Ami = amikacin, Mero = meropenem, Vanco = vancomycin, Line = linezolid, Posa = posaconazole (p.o.), Mica = micafungin (i.v.), Amb = liposomal amphotericin B. The patient also received prophylactic acyclovir and sulfamethoxazole/trimethoprim (TMP/SMZ) during treatment. c Complete Blood Count (CBC) timeline. ANC (blue), platelet count (green), Hemoglobin (red). Transfusion events (green: platelet transfusion, red: pRBC transfusion) and G-CSF support (blue bar) are integrated in the curve. d Dynamics of Serum Inflammatory Markers. Infectious complications are superimposed above the graph. e Histopathologic analysis of BM biopsies demonstrating severe BM aplasia 1 month after CAR T-cell transfusion (Day 32, upper panel) and evidence of recovering hematopoiesis following autologous stem cell transfer (Autopsy, lower panel). Immunohistochemical staining for myeloperoxidase (= MPO) highlighting strong activation of myelopoiesis (right panel)
Fig. 2 Radiographic evidence of partial response to Axi-cel after 36 days. Contrast-enhanced CT abdomen (axial view) displaying pleural manifestations before (a) and after (b) CAR T-cell treatment. Involved paraaortic lymph nodes (red arrows) demonstrate an interval decrease in size (c-d, e-f). The inset of panel F depicts splenic hypodensities consistent with necrosis of tumor tissue secondary to immune therapy and a reduction of splenomegaly. G Graphical depiction of response over time. Tumor extent was quantified as the sum of the product of perpendicular diameters according to Lugano criteria over 3 time points and is graphed on the y-axis. H Timeline of LDH levels (U/l). The increase in LDH levels at day 25 correlated with the gastrointestinal toxicity and liver dysfunction
Fig. 3 Multi-organ toxicity secondary to CD19-directed CAR T-cell therapy. a Contrast-enhanced CT abdomen demonstrating a non-inflamed baseline state of GI mucosal tissue prior to CAR T therapy. b Panmural swelling of the sigma (left panel), ascending colon (middle panel), and stomach. c Non-pathologic CT of the brain. d Axial FLAIR-weighted (left), T1-weighted contrast-enhanced (middle), and diffusion-weighted (right) MRI displaying no evidence of cerebral edema, white matter lesions, diffusion restriction, microbleeds, meningeal enhancement or contrast enhancing lesions. e High-resolution CT thorax with bilateral fungal infiltrates observing the typical halo configuration 6 weeks prior to CAR T-cell transfusion. f On day − 3 the right-sided infiltrates have decreased in size. The left lung is collapsed due to malignant pleural effusion. g Lung parenchyma exhibiting an infiltration of non-dimorphic blastoconidial morphology consistent with Candida glabrata. h PAS staining of a lung specimen highlights septated hiphae and acute-angle branching, features consistent of with aspergillus infection
During lymphodepletion the patient developed an upper respiratory infection, presenting with a non-productive cough and a sputum culture positive for Bordetella bronchiseptica, which resolved clinically after antibiotic treatment with piperacillin/tazobactam. On day 7, the patient developed fever with a stable cardiopulmonary function and concomitant IL-6 rise (Fig. 1d), which was classified as CRS grade I according to ASTCT consensus grading [7] in the absence of positive blood cultures and other foci. Due to persistent fever refractory to antipyretic treatment, four total doses of tocilizumab (8 mg/kg) were applied over 36 h. Starting on day 9, the patient deteriorated neurologically with a depressed state of consciousness prompting the diagnosis of grade IV ICANS. The patient was transferred to the neurological ICU, and high-dose corticosteroids (methylprednisolone 1000 mg daily) were initiated. CSF-analysis displayed subtle pleocytosis, but revealed no signs of CNS infection (viral, bacterial and fungal) or meningeal involvement of the DLBCL. CT and MR imaging of the brain exhibited none of the pathological findings reported for ICANS [8] or CNS infection [9](Fig. 3c-d). After 5 days of high-dose methylprednisolone, the patient’s neurological status slowly improved, and corticosteroids could be tapered.
Partial response to Axicabtagene-Ciloleucel after 36 days according to Lugano criteria
While the patient’s initial clinical course was fraught with complications, CT staging performed at day 36 demonstrated a partial response to CAR T-cell therapy according to Lugano and Lyric criteria (Fig. 2a-g). This was particularly evident for the pleural manifestations of the underlying DLBCL, which was accompanied by an interval decrease in pleural effusions and subjective dyspnea (Fig. 2a-b). Multiple nodal sites including paraaortic (Fig. 2c-d) and parailiac lymph nodes (Fig. 2e-f) exhibited significant regression of tumor size (Fig. 2g). Moreover, the patient displayed splenic hypodensities consistent with either tumor tissue necrosis or infection-associated inflammatory changes (inset, Fig. 2f). These CT-morphologic findings were accompanied by a decrease of LDH levels (Fig. 2h).
Prolonged cytopenia lead to the development of severe neutropenic colitis and fatal fungal pneumonia
The patient presented with significant myelotoxicity and sustained transfusion dependency after CAR T-cell administration (Fig. 1c). The overall duration of profound neutropenia – defined as an ANC < 100/μl [10] – was 52 days. Because of the severity of ICANS, the clinicians chose to hold G-CSF during this time period due to concerns for risk of worsening toxicity [11].
While receiving broad anti-infectives (acyclovir, TMP/SMZ, posaconazole, meropenem), the patient developed breakthrough septic shock on day 24. He exhibited fever (39.5 °C), hypotension (70/30 mmHg), tachycardia (160/min), as well as lactic acidosis (lactate: 10.7 mmol/l). The patient was non-conversant, non-oriented, and was not able to localize symptoms. However, he had described epigastric tenderness and subtle changes in stool consistency and frequency on the previous day. As a result, abdominal CT imaging was obtained, which displayed severe pancolitis, as evidenced by pronounced mucosal thickening with edematous changes ranging from the ascending colon to the rectum (Fig. 3a-b). Labs were notable for an acute spike of serum inflammatory parameters (Il-6 > 500.000 pg/ml, CRP 5.7 mg/dl, Procalcitonin 11.2 ng/ml, Fig. 1d). Following ICU transfer, high-dose vasopressor support with norepinephrine was initiated together with volume resuscitation to maintain organ perfusion. Due to progressive loss of consciousness the patient was intubated and mechanically ventilated. To control the proinflammatory state, extracorporeal cytokine absorption (Cytosorb®) was performed, which resulted in a decrease of soluble inflammatory markers in the subsequent days. Arterial blood cultures were positive for vancomycin-resistant enterococci (VRE), and the antibiotic treatment was escalated to include linezolid along with meropenem (Fig. 1b). The ICU team transitioned antifungal prophylaxis from posaconazole to an echinocandine (micafungin 50 mg IV) due to ECG changes and concerns for drug interactions on day 24. Though he remained in critical condition, in the coming weeks his clinical condition stabilized and both the catecholamine rate and volume support could be reduced. To determine the origin of sustained myelosuppression, a bone marrow biopsy was obtained, which depicted a hypocellular marrow and severe aplasia affecting all hematopoietic lineages (Fig. 1e). On days 41 and 49, surveillance blood cultures were positive for Candida glabrata, a commensal fungal organism of human mucosal tissues [12] harboring an intrinsic azole resistance [13]. Susceptibility testing confirmed the azole-resistance of C. glabrata isolates. The antimycotic therapy was escalated from micafungin to liposomal amphotericin B. C. glabrata likely disseminated to the bloodstream secondary to the described gastrointestinal toxicity and was previously discovered on rectal swab (Fig. 1b) and fecal culture (day − 51).
Due to sustained neutropenia, BM aplasia and the availability of a suitable apheresis product, the CAR T-cell Taskforce proceeded with a stem cell boost of previously collected autologous CD34+ cells (3,1 × 106 cells) on day 46. The combination of a sudden rise in serum inflammatory markers and a strongly positive serum galactomannan (GM) assay on day 49 prompted diagnostic bronchoscopy, which revealed a diffuse infiltrate of alveolar and peri-bronchial tissue by Aspergillus fumigatus, consistent with fulminant invasive fungal pneumonia. Over the next week, the patient became increasingly hemodynamically unstable with poor peripheral oxygenation. Repeat bronchoscopy with bronchial lavage was positive for A. fumigatus and C. glabrata. After 50 days of G-CSF refractory aplasia, the autologous stem cells slowly engrafted leading to neutrophil recovery. However, this likely exacerbated the local inflammatory reaction in the lung, contributing to rapid deterioration of his respiratory status. Despite extensive supportive measures, the patient died on day 58 after CAR T-cell transfusion. Cause of death was confirmed by autopsy as invasive fungal pneumonia with multi-organ septic spread. Post-mortem examination revealed Candida spores in intestinal, colonic and rectal tissue. Of note, histopathologic BM analysis revealed signs of burgeoning hematopoietic regeneration (Fig. 1e).
Discussion and conclusions
Recent studies have shed light on the high incidence of prolonged and profound neutropenia after adoptive immunotherapy with CD19-specific CAR T-cells [1–3]. Clinical sequalae include severe infectious complications, which have emerged as the number one cause of long-term non-relapse mortality after CAR T-cell therapy [14]. In a seminal study, Hill and colleagues demonstrate that infectious complications are common with a cumulative incidence of 23% in the first 28 days after CAR T-cell transfusion and 14% between days 29–90. While bacterial infections were most common in the first month, viral infections – especially respiratory viruses – predominated after day 29, likely as a result of an impaired adaptive immune response due to B-cell aplasia [15]. Overall, most infections were mild to moderate and fatal infections were rare. Invasive mold infections were uncommon, ranging from 1 to 7% in CAR T-cell recipients [15–17]. In multivariate analyses, the use of systemic corticosteroids for the management of CRS or ICANS has emerged as a major risk factor of infection [18]. Certain inflammatory signatures – such as the “double peaks of IL-6” pattern observed in our patient – have been shown to confer an especially high risk of life-threatening infection [19].
This case highlights the combination of factors that precipitate a high risk of infectious complications in a CAR T-cell patient. First, the heavily pre-treated patient displayed B-cell aplasia and a diminished hematopoietic reserve (e.g. trilineage cytopenia) prior to lymphodepletion. Second, the patient developed classic complications of CAR T-cell therapy such as CRS and severe and prolonged ICANS, reflecting a pro-inflammatory state that represents an important risk factor for developing infections in CAR T-cell patients [16]. The subsequent application of high-dose corticosteroids impaired both innate and adaptive immunity [20]. Third, pancytopenia was profound, prolonged and not able to be reverted by growth factor support. Fourth, the patient had a history of infectious complications, including a course of fungal pneumonia 6 weeks prior to lymphodepletion, likely flaring up in the setting of the above three factors.
Our patient developed severe septic shock secondary to neutropenic colitis on day 24, highlighting the risk of a watch-and-wait approach to prolonged neutropenia after CAR T-cell therapy. A two-pronged approach to management appears prescient. On the one hand, measures to propagate hematopoietic recovery should be exhausted (causal therapy). This can range from G-CSF stimulation, to a trial of pulse-dose corticosteroids or anti-cytokine therapy (e.g. Anakinra, Tocilizumab), to a stem cell boost as a last resort in lymphoma patients who have undergone prior autologous stem cell transplantation. On the other hand, clinicians should be at high alert for infectious complications and adapt their infection surveillance and anti-infective prophylactic strategies accordingly. For example, therapeutic drug monitoring of posaconazole and meropenem levels may have revealed subtherapeutic dosing of these anti-infective agents in this patient [21]. The role of antifungal prophylaxis in the CAR T-cell patient remains inconclusive. Adequately powered studies addressing the duration of neutropenia after CAR T-cell therapy, and potential clinical determinants of invasive fungal infections, will be critical to gauge the benefit of antifungal prophylaxis in this patient collective.
Candida species are a leading cause of fungus-associated morbidity and mortality in severely immunocompromised patients [21]. On day 41, this patient developed breakthrough C. glabrata Candidemia on micafungin, in the setting of both underlying colonization and neutropenic colitis. A recent report implicated the gastrointestinal tract as major source of echinocandin drug resistance in a murine model of C. glabrata colonization and systemic dissemination [22]. Of note, breakthrough Candida infections on micafungin may occur at the employed dose level (50 mg/day IV), suggesting that this dose may have been inadequate to prevent subsequent Candidemia [23]. Though cases of C. glabrata colitis are extremely rare [24], an opportunistic infection could not be ruled out given that C. glabrata infiltrates were discovered in enteral and colonic mucosal tissue on post-mortem examination. Importantly, the patients’ clinical status deteriorated only after the stem cell boost resulted in signs of hematopoietic recovery. The paradoxical worsening of the pulmonary A. fumigatus infection is consistent with immune reconstitution inflammatory syndrome (IRIS), which has been previously described for HIV/AIDS [25] and for severely neutropenic patients with IPA [26]. In conclusion, this case emphasizes that infectious complications secondary to prolonged cytopenia influence non-relapse mortality after CAR T-cell therapy.
Abbreviations
ALCAbsolute Lymphocyte Count
ANCAbsolute Neutrophil Count
BMBone Marrow
CARChimeric antigen receptor
CBCComplete Blood Count
CRSCytokine release syndrome
CTCAECommon Terminology Criteria for Adverse Events
DLBCLDiffuse large B-cell lymphoma
FFPFresh frozen plasma
FLAIRFluid-attenuated inversion recovery
Flu/CyFludarabine/Cyclophosphamide
G-CSFGranulocyte colony stimulating factor
GIGastrointestinal
GMGalactomannan
HSPCsHematopoietic stem and progenitor cells
ICANSImmune effector cell-associated neurotoxicity syndrome
ICE-scoreImmune Effector Cell-associated Encephalopathy score
ICUIntensive care unit
IPAInvasive pulmonary aspergillosis
LDHLactate Dehydrogenase
LYRICLymphoma response to immunomodulatory therapy criteria
MDRDModification of Diet in Renal Disease
MPOMyeloperoxidase
PASPeriodic acid-Schiff
PBSCPeripheral Blood Stem Cell
VREVancomycin-resistant Enterococcus
WBCWhite Blood Count
Publisher’s Note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
Acknowledgements
Not applicable.
Authors’ contributions
The original manuscript was written by KR. KR and WGK prepared the figures. MR performed the histological examination of the bone marrow. MS reviewed and edited the manuscript. The other authors (VB1, VB2, CS, PK, FS, KD, LvB, JS, OW, MD, MvBB) contributed to patient management and participated in drafting and editing the manuscript. All authors read and approved the final manuscript.
Funding
Not applicable. Open Access funding enabled and organized by Projekt DEAL.
Availability of data and materials
The authors did not use any database, software, or tools for the writing of this manuscript.
Ethics approval and consent to participate
The authors obtained consent from the deceased patient’s next-of-kin to participate.
Consent for publication
Written informed consent was obtained from the patient’s next-of-kin for publication of this Case report and any accompanying images. A copy of the written consent is available for review by the Editor of this journal.
Competing interests
The authors declare that they have no competing interests related with this case report. | CYCLOPHOSPHAMIDE, DOXORUBICIN HYDROCHLORIDE, METHYLPREDNISOLONE, PREDNISOLONE, RITUXIMAB, VINCRISTINE | DrugsGivenReaction | CC BY | 33509115 | 18,947,434 | 2021-01-28 |
Give an alphabetized list of all active substances of drugs taken by the patient who experienced 'Candida infection'. | Severe Candida glabrata pancolitis and fatal Aspergillus fumigatus pulmonary infection in the setting of bone marrow aplasia after CD19-directed CAR T-cell therapy - a case report.
BACKGROUND
Prolonged myelosuppression following CD19-directed CAR T-cell transfusion represents an important, yet underreported, adverse event. The resulting neutropenia and multifactorial immunosuppression can facilitate severe infectious complications.
METHODS
We describe the clinical course of a 59-year-old patient with relapsed/refractory DLBCL who received Axicabtagene-Ciloleucel (Axi-cel). The patient developed ASTCT grade I CRS and grade IV ICANS, necessitating admission to the neurological ICU and prolonged application of high-dose corticosteroids and other immunosuppressive agents. Importantly, neutropenia was profound (ANC < 100/μl), G-CSF-refractory, and prolonged, lasting more than 50 days. The patient developed severe septic shock 3 weeks after CAR transfusion while receiving anti-fungal prophylaxis with micafungin. His clinical status stabilized with broad anti-infective treatment and intensive supportive measures. An autologous stem cell backup was employed on day 46 to support hematopoietic recovery. Although the counts of the patient eventually started to recover, he developed an invasive pulmonary aspergillosis, which ultimately lead to respiratory failure and death. Postmortem examination revealed signs of Candida glabrata pancolitis.
CONCLUSIONS
This case highlights the increased risk for fatal infectious complications in patients who present with profound and prolonged cytopenia after CAR T-cell therapy. We describe a rare case of C. glabrata pancolitis associated with multifactorial immunosuppression. Although our patient succumbed to a fatal fungal infection, autologous stem cell boost was able to spur hematopoiesis and may represent an important therapeutic strategy for DLBCL patients with CAR T-cell associated bone marrow aplasia who have underwent prior stem cell harvest.
Background
When CD19-directed Chimeric Antigen Receptor (CAR) T-cell therapies were first introduced into the clinical setting, a set of distinctive side effects were observed, including Cytokine Release Syndrome (CRS) and immune effector cell-associated neurotoxicity syndrome (ICANS). As these treatments transition from large clinical trials to real-world implementation, new nuances of the side effect spectrum have emerged. This includes the observation that patients can present not only with grade 3–4 cytopenia (CTCAE v5.0), but also a syndrome of persistent cytopenia after CAR T-cell transfusion [1, 2]. Hematologic toxicity is common with one study demonstrating that neutropenia, thrombocytopenia and anemia occur in 94, 80 and 51% of patients respectively [3]. Risk factors for hematotoxicity include CRS grade, baseline cytopenia, and prior allogeneic stem cell transplantation within the last year [2, 3]. The fact that baseline hematopoietic reserve contributes to cytopenia in CAR T-cell patients may explain the variability in the incidence of hematoxicity in the real-world setting compared to the large registration trials, which set stringent hematologic exclusion criteria [4, 5]. The clinical utility of therapeutic rescue strategies that mitigate the risk of infectious complications secondary to long-term bone marrow (BM) aplasia, such as early autologous stem cell boost or Eltrombopag, remains unknown. Moreover, the relative paucity of reports concerning severe and life-threatening infections in the reported CD19-directed CAR T-cell trials necessitates the presentation of distinctive clinical courses that underline the risks of persistent cytopenia after CAR T-cell therapy in a real-world setting.
Case presentation
The 59-year-old male patient was initially diagnosed with stage IIIA follicular lymphoma in January 2018, which transformed to germinal center B-cell like DLBCL in October of the same year. Refractory to multiple cycles of Rituximab-based immunochemotherapy (Fig. 1a), the patient underwent leukapheresis for CAR T-cell therapy in April 2019. The patient experienced significant lymphoma progression during the manufacturing process of Axicabtagene ciloleucel (Axi-cel), manifesting itself in the form of malignant pleural effusions and progressive lymphadenopathy (Fig. 2a,c,e). In the six-week period between leukapheresis and lymphodepletion, the patient remained severely neutropenic after R-CHOP and developed possible invasive fungal disease (IFD) [6] (Fig. 3e) as well as E. coli septicemia secondary to a urinary tract infection. These infections were treated successfully with liposomal amphotericin B and piperacillin/tazobactam. Prior to lymphodepletion (D-5), the patient presented with an ECOG performance status of 1, intact renal and liver function, while observing residually depressed blood counts (WBC 1270/μl, ANC 700/μl, ALC 390/μl, Hemoglobin 7.2 g/dl, Platelets 20 G/l). BM histopathology showed a hypocellular marrow with no evidence of lymphoma infiltration. Analysis of lymphocyte subpopulations demonstrated severe B-cell aplasia and decreased absolute CD4+ (84/μl) and CD8+ (271/μl) counts. His anti-infective prophylaxis consisted of a combination of acyclovir, sulfamethoxazole/trimethoprim (TMP/SMZ), and posaconazole. The fludarabine/cyclophosphamide lympho-preparative regimen was applied on days − 5 to − 3 according to the provider’s protocol, followed by CAR T-cell transfusion on day 0.
Fig. 1 Overview of CAR T-cell mediated hematotoxicity and infectious complications. a Treatment course prior to CAR T-cell therapy. b Timeline of infectious complications during CAR T-cell treatment course. Positive microbiologic culture results are underlined. Bottom: Overview of utilized anti-infectives with the respective bars displaying the length of treatment. P/T = piperacillin/tazobactam, Ami = amikacin, Mero = meropenem, Vanco = vancomycin, Line = linezolid, Posa = posaconazole (p.o.), Mica = micafungin (i.v.), Amb = liposomal amphotericin B. The patient also received prophylactic acyclovir and sulfamethoxazole/trimethoprim (TMP/SMZ) during treatment. c Complete Blood Count (CBC) timeline. ANC (blue), platelet count (green), Hemoglobin (red). Transfusion events (green: platelet transfusion, red: pRBC transfusion) and G-CSF support (blue bar) are integrated in the curve. d Dynamics of Serum Inflammatory Markers. Infectious complications are superimposed above the graph. e Histopathologic analysis of BM biopsies demonstrating severe BM aplasia 1 month after CAR T-cell transfusion (Day 32, upper panel) and evidence of recovering hematopoiesis following autologous stem cell transfer (Autopsy, lower panel). Immunohistochemical staining for myeloperoxidase (= MPO) highlighting strong activation of myelopoiesis (right panel)
Fig. 2 Radiographic evidence of partial response to Axi-cel after 36 days. Contrast-enhanced CT abdomen (axial view) displaying pleural manifestations before (a) and after (b) CAR T-cell treatment. Involved paraaortic lymph nodes (red arrows) demonstrate an interval decrease in size (c-d, e-f). The inset of panel F depicts splenic hypodensities consistent with necrosis of tumor tissue secondary to immune therapy and a reduction of splenomegaly. G Graphical depiction of response over time. Tumor extent was quantified as the sum of the product of perpendicular diameters according to Lugano criteria over 3 time points and is graphed on the y-axis. H Timeline of LDH levels (U/l). The increase in LDH levels at day 25 correlated with the gastrointestinal toxicity and liver dysfunction
Fig. 3 Multi-organ toxicity secondary to CD19-directed CAR T-cell therapy. a Contrast-enhanced CT abdomen demonstrating a non-inflamed baseline state of GI mucosal tissue prior to CAR T therapy. b Panmural swelling of the sigma (left panel), ascending colon (middle panel), and stomach. c Non-pathologic CT of the brain. d Axial FLAIR-weighted (left), T1-weighted contrast-enhanced (middle), and diffusion-weighted (right) MRI displaying no evidence of cerebral edema, white matter lesions, diffusion restriction, microbleeds, meningeal enhancement or contrast enhancing lesions. e High-resolution CT thorax with bilateral fungal infiltrates observing the typical halo configuration 6 weeks prior to CAR T-cell transfusion. f On day − 3 the right-sided infiltrates have decreased in size. The left lung is collapsed due to malignant pleural effusion. g Lung parenchyma exhibiting an infiltration of non-dimorphic blastoconidial morphology consistent with Candida glabrata. h PAS staining of a lung specimen highlights septated hiphae and acute-angle branching, features consistent of with aspergillus infection
During lymphodepletion the patient developed an upper respiratory infection, presenting with a non-productive cough and a sputum culture positive for Bordetella bronchiseptica, which resolved clinically after antibiotic treatment with piperacillin/tazobactam. On day 7, the patient developed fever with a stable cardiopulmonary function and concomitant IL-6 rise (Fig. 1d), which was classified as CRS grade I according to ASTCT consensus grading [7] in the absence of positive blood cultures and other foci. Due to persistent fever refractory to antipyretic treatment, four total doses of tocilizumab (8 mg/kg) were applied over 36 h. Starting on day 9, the patient deteriorated neurologically with a depressed state of consciousness prompting the diagnosis of grade IV ICANS. The patient was transferred to the neurological ICU, and high-dose corticosteroids (methylprednisolone 1000 mg daily) were initiated. CSF-analysis displayed subtle pleocytosis, but revealed no signs of CNS infection (viral, bacterial and fungal) or meningeal involvement of the DLBCL. CT and MR imaging of the brain exhibited none of the pathological findings reported for ICANS [8] or CNS infection [9](Fig. 3c-d). After 5 days of high-dose methylprednisolone, the patient’s neurological status slowly improved, and corticosteroids could be tapered.
Partial response to Axicabtagene-Ciloleucel after 36 days according to Lugano criteria
While the patient’s initial clinical course was fraught with complications, CT staging performed at day 36 demonstrated a partial response to CAR T-cell therapy according to Lugano and Lyric criteria (Fig. 2a-g). This was particularly evident for the pleural manifestations of the underlying DLBCL, which was accompanied by an interval decrease in pleural effusions and subjective dyspnea (Fig. 2a-b). Multiple nodal sites including paraaortic (Fig. 2c-d) and parailiac lymph nodes (Fig. 2e-f) exhibited significant regression of tumor size (Fig. 2g). Moreover, the patient displayed splenic hypodensities consistent with either tumor tissue necrosis or infection-associated inflammatory changes (inset, Fig. 2f). These CT-morphologic findings were accompanied by a decrease of LDH levels (Fig. 2h).
Prolonged cytopenia lead to the development of severe neutropenic colitis and fatal fungal pneumonia
The patient presented with significant myelotoxicity and sustained transfusion dependency after CAR T-cell administration (Fig. 1c). The overall duration of profound neutropenia – defined as an ANC < 100/μl [10] – was 52 days. Because of the severity of ICANS, the clinicians chose to hold G-CSF during this time period due to concerns for risk of worsening toxicity [11].
While receiving broad anti-infectives (acyclovir, TMP/SMZ, posaconazole, meropenem), the patient developed breakthrough septic shock on day 24. He exhibited fever (39.5 °C), hypotension (70/30 mmHg), tachycardia (160/min), as well as lactic acidosis (lactate: 10.7 mmol/l). The patient was non-conversant, non-oriented, and was not able to localize symptoms. However, he had described epigastric tenderness and subtle changes in stool consistency and frequency on the previous day. As a result, abdominal CT imaging was obtained, which displayed severe pancolitis, as evidenced by pronounced mucosal thickening with edematous changes ranging from the ascending colon to the rectum (Fig. 3a-b). Labs were notable for an acute spike of serum inflammatory parameters (Il-6 > 500.000 pg/ml, CRP 5.7 mg/dl, Procalcitonin 11.2 ng/ml, Fig. 1d). Following ICU transfer, high-dose vasopressor support with norepinephrine was initiated together with volume resuscitation to maintain organ perfusion. Due to progressive loss of consciousness the patient was intubated and mechanically ventilated. To control the proinflammatory state, extracorporeal cytokine absorption (Cytosorb®) was performed, which resulted in a decrease of soluble inflammatory markers in the subsequent days. Arterial blood cultures were positive for vancomycin-resistant enterococci (VRE), and the antibiotic treatment was escalated to include linezolid along with meropenem (Fig. 1b). The ICU team transitioned antifungal prophylaxis from posaconazole to an echinocandine (micafungin 50 mg IV) due to ECG changes and concerns for drug interactions on day 24. Though he remained in critical condition, in the coming weeks his clinical condition stabilized and both the catecholamine rate and volume support could be reduced. To determine the origin of sustained myelosuppression, a bone marrow biopsy was obtained, which depicted a hypocellular marrow and severe aplasia affecting all hematopoietic lineages (Fig. 1e). On days 41 and 49, surveillance blood cultures were positive for Candida glabrata, a commensal fungal organism of human mucosal tissues [12] harboring an intrinsic azole resistance [13]. Susceptibility testing confirmed the azole-resistance of C. glabrata isolates. The antimycotic therapy was escalated from micafungin to liposomal amphotericin B. C. glabrata likely disseminated to the bloodstream secondary to the described gastrointestinal toxicity and was previously discovered on rectal swab (Fig. 1b) and fecal culture (day − 51).
Due to sustained neutropenia, BM aplasia and the availability of a suitable apheresis product, the CAR T-cell Taskforce proceeded with a stem cell boost of previously collected autologous CD34+ cells (3,1 × 106 cells) on day 46. The combination of a sudden rise in serum inflammatory markers and a strongly positive serum galactomannan (GM) assay on day 49 prompted diagnostic bronchoscopy, which revealed a diffuse infiltrate of alveolar and peri-bronchial tissue by Aspergillus fumigatus, consistent with fulminant invasive fungal pneumonia. Over the next week, the patient became increasingly hemodynamically unstable with poor peripheral oxygenation. Repeat bronchoscopy with bronchial lavage was positive for A. fumigatus and C. glabrata. After 50 days of G-CSF refractory aplasia, the autologous stem cells slowly engrafted leading to neutrophil recovery. However, this likely exacerbated the local inflammatory reaction in the lung, contributing to rapid deterioration of his respiratory status. Despite extensive supportive measures, the patient died on day 58 after CAR T-cell transfusion. Cause of death was confirmed by autopsy as invasive fungal pneumonia with multi-organ septic spread. Post-mortem examination revealed Candida spores in intestinal, colonic and rectal tissue. Of note, histopathologic BM analysis revealed signs of burgeoning hematopoietic regeneration (Fig. 1e).
Discussion and conclusions
Recent studies have shed light on the high incidence of prolonged and profound neutropenia after adoptive immunotherapy with CD19-specific CAR T-cells [1–3]. Clinical sequalae include severe infectious complications, which have emerged as the number one cause of long-term non-relapse mortality after CAR T-cell therapy [14]. In a seminal study, Hill and colleagues demonstrate that infectious complications are common with a cumulative incidence of 23% in the first 28 days after CAR T-cell transfusion and 14% between days 29–90. While bacterial infections were most common in the first month, viral infections – especially respiratory viruses – predominated after day 29, likely as a result of an impaired adaptive immune response due to B-cell aplasia [15]. Overall, most infections were mild to moderate and fatal infections were rare. Invasive mold infections were uncommon, ranging from 1 to 7% in CAR T-cell recipients [15–17]. In multivariate analyses, the use of systemic corticosteroids for the management of CRS or ICANS has emerged as a major risk factor of infection [18]. Certain inflammatory signatures – such as the “double peaks of IL-6” pattern observed in our patient – have been shown to confer an especially high risk of life-threatening infection [19].
This case highlights the combination of factors that precipitate a high risk of infectious complications in a CAR T-cell patient. First, the heavily pre-treated patient displayed B-cell aplasia and a diminished hematopoietic reserve (e.g. trilineage cytopenia) prior to lymphodepletion. Second, the patient developed classic complications of CAR T-cell therapy such as CRS and severe and prolonged ICANS, reflecting a pro-inflammatory state that represents an important risk factor for developing infections in CAR T-cell patients [16]. The subsequent application of high-dose corticosteroids impaired both innate and adaptive immunity [20]. Third, pancytopenia was profound, prolonged and not able to be reverted by growth factor support. Fourth, the patient had a history of infectious complications, including a course of fungal pneumonia 6 weeks prior to lymphodepletion, likely flaring up in the setting of the above three factors.
Our patient developed severe septic shock secondary to neutropenic colitis on day 24, highlighting the risk of a watch-and-wait approach to prolonged neutropenia after CAR T-cell therapy. A two-pronged approach to management appears prescient. On the one hand, measures to propagate hematopoietic recovery should be exhausted (causal therapy). This can range from G-CSF stimulation, to a trial of pulse-dose corticosteroids or anti-cytokine therapy (e.g. Anakinra, Tocilizumab), to a stem cell boost as a last resort in lymphoma patients who have undergone prior autologous stem cell transplantation. On the other hand, clinicians should be at high alert for infectious complications and adapt their infection surveillance and anti-infective prophylactic strategies accordingly. For example, therapeutic drug monitoring of posaconazole and meropenem levels may have revealed subtherapeutic dosing of these anti-infective agents in this patient [21]. The role of antifungal prophylaxis in the CAR T-cell patient remains inconclusive. Adequately powered studies addressing the duration of neutropenia after CAR T-cell therapy, and potential clinical determinants of invasive fungal infections, will be critical to gauge the benefit of antifungal prophylaxis in this patient collective.
Candida species are a leading cause of fungus-associated morbidity and mortality in severely immunocompromised patients [21]. On day 41, this patient developed breakthrough C. glabrata Candidemia on micafungin, in the setting of both underlying colonization and neutropenic colitis. A recent report implicated the gastrointestinal tract as major source of echinocandin drug resistance in a murine model of C. glabrata colonization and systemic dissemination [22]. Of note, breakthrough Candida infections on micafungin may occur at the employed dose level (50 mg/day IV), suggesting that this dose may have been inadequate to prevent subsequent Candidemia [23]. Though cases of C. glabrata colitis are extremely rare [24], an opportunistic infection could not be ruled out given that C. glabrata infiltrates were discovered in enteral and colonic mucosal tissue on post-mortem examination. Importantly, the patients’ clinical status deteriorated only after the stem cell boost resulted in signs of hematopoietic recovery. The paradoxical worsening of the pulmonary A. fumigatus infection is consistent with immune reconstitution inflammatory syndrome (IRIS), which has been previously described for HIV/AIDS [25] and for severely neutropenic patients with IPA [26]. In conclusion, this case emphasizes that infectious complications secondary to prolonged cytopenia influence non-relapse mortality after CAR T-cell therapy.
Abbreviations
ALCAbsolute Lymphocyte Count
ANCAbsolute Neutrophil Count
BMBone Marrow
CARChimeric antigen receptor
CBCComplete Blood Count
CRSCytokine release syndrome
CTCAECommon Terminology Criteria for Adverse Events
DLBCLDiffuse large B-cell lymphoma
FFPFresh frozen plasma
FLAIRFluid-attenuated inversion recovery
Flu/CyFludarabine/Cyclophosphamide
G-CSFGranulocyte colony stimulating factor
GIGastrointestinal
GMGalactomannan
HSPCsHematopoietic stem and progenitor cells
ICANSImmune effector cell-associated neurotoxicity syndrome
ICE-scoreImmune Effector Cell-associated Encephalopathy score
ICUIntensive care unit
IPAInvasive pulmonary aspergillosis
LDHLactate Dehydrogenase
LYRICLymphoma response to immunomodulatory therapy criteria
MDRDModification of Diet in Renal Disease
MPOMyeloperoxidase
PASPeriodic acid-Schiff
PBSCPeripheral Blood Stem Cell
VREVancomycin-resistant Enterococcus
WBCWhite Blood Count
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Acknowledgements
Not applicable.
Authors’ contributions
The original manuscript was written by KR. KR and WGK prepared the figures. MR performed the histological examination of the bone marrow. MS reviewed and edited the manuscript. The other authors (VB1, VB2, CS, PK, FS, KD, LvB, JS, OW, MD, MvBB) contributed to patient management and participated in drafting and editing the manuscript. All authors read and approved the final manuscript.
Funding
Not applicable. Open Access funding enabled and organized by Projekt DEAL.
Availability of data and materials
The authors did not use any database, software, or tools for the writing of this manuscript.
Ethics approval and consent to participate
The authors obtained consent from the deceased patient’s next-of-kin to participate.
Consent for publication
Written informed consent was obtained from the patient’s next-of-kin for publication of this Case report and any accompanying images. A copy of the written consent is available for review by the Editor of this journal.
Competing interests
The authors declare that they have no competing interests related with this case report. | CYCLOPHOSPHAMIDE, DOXORUBICIN HYDROCHLORIDE, METHYLPREDNISOLONE, PREDNISOLONE, RITUXIMAB, VINCRISTINE | DrugsGivenReaction | CC BY | 33509115 | 18,947,434 | 2021-01-28 |
Give an alphabetized list of all active substances of drugs taken by the patient who experienced 'Colitis'. | Severe Candida glabrata pancolitis and fatal Aspergillus fumigatus pulmonary infection in the setting of bone marrow aplasia after CD19-directed CAR T-cell therapy - a case report.
BACKGROUND
Prolonged myelosuppression following CD19-directed CAR T-cell transfusion represents an important, yet underreported, adverse event. The resulting neutropenia and multifactorial immunosuppression can facilitate severe infectious complications.
METHODS
We describe the clinical course of a 59-year-old patient with relapsed/refractory DLBCL who received Axicabtagene-Ciloleucel (Axi-cel). The patient developed ASTCT grade I CRS and grade IV ICANS, necessitating admission to the neurological ICU and prolonged application of high-dose corticosteroids and other immunosuppressive agents. Importantly, neutropenia was profound (ANC < 100/μl), G-CSF-refractory, and prolonged, lasting more than 50 days. The patient developed severe septic shock 3 weeks after CAR transfusion while receiving anti-fungal prophylaxis with micafungin. His clinical status stabilized with broad anti-infective treatment and intensive supportive measures. An autologous stem cell backup was employed on day 46 to support hematopoietic recovery. Although the counts of the patient eventually started to recover, he developed an invasive pulmonary aspergillosis, which ultimately lead to respiratory failure and death. Postmortem examination revealed signs of Candida glabrata pancolitis.
CONCLUSIONS
This case highlights the increased risk for fatal infectious complications in patients who present with profound and prolonged cytopenia after CAR T-cell therapy. We describe a rare case of C. glabrata pancolitis associated with multifactorial immunosuppression. Although our patient succumbed to a fatal fungal infection, autologous stem cell boost was able to spur hematopoiesis and may represent an important therapeutic strategy for DLBCL patients with CAR T-cell associated bone marrow aplasia who have underwent prior stem cell harvest.
Background
When CD19-directed Chimeric Antigen Receptor (CAR) T-cell therapies were first introduced into the clinical setting, a set of distinctive side effects were observed, including Cytokine Release Syndrome (CRS) and immune effector cell-associated neurotoxicity syndrome (ICANS). As these treatments transition from large clinical trials to real-world implementation, new nuances of the side effect spectrum have emerged. This includes the observation that patients can present not only with grade 3–4 cytopenia (CTCAE v5.0), but also a syndrome of persistent cytopenia after CAR T-cell transfusion [1, 2]. Hematologic toxicity is common with one study demonstrating that neutropenia, thrombocytopenia and anemia occur in 94, 80 and 51% of patients respectively [3]. Risk factors for hematotoxicity include CRS grade, baseline cytopenia, and prior allogeneic stem cell transplantation within the last year [2, 3]. The fact that baseline hematopoietic reserve contributes to cytopenia in CAR T-cell patients may explain the variability in the incidence of hematoxicity in the real-world setting compared to the large registration trials, which set stringent hematologic exclusion criteria [4, 5]. The clinical utility of therapeutic rescue strategies that mitigate the risk of infectious complications secondary to long-term bone marrow (BM) aplasia, such as early autologous stem cell boost or Eltrombopag, remains unknown. Moreover, the relative paucity of reports concerning severe and life-threatening infections in the reported CD19-directed CAR T-cell trials necessitates the presentation of distinctive clinical courses that underline the risks of persistent cytopenia after CAR T-cell therapy in a real-world setting.
Case presentation
The 59-year-old male patient was initially diagnosed with stage IIIA follicular lymphoma in January 2018, which transformed to germinal center B-cell like DLBCL in October of the same year. Refractory to multiple cycles of Rituximab-based immunochemotherapy (Fig. 1a), the patient underwent leukapheresis for CAR T-cell therapy in April 2019. The patient experienced significant lymphoma progression during the manufacturing process of Axicabtagene ciloleucel (Axi-cel), manifesting itself in the form of malignant pleural effusions and progressive lymphadenopathy (Fig. 2a,c,e). In the six-week period between leukapheresis and lymphodepletion, the patient remained severely neutropenic after R-CHOP and developed possible invasive fungal disease (IFD) [6] (Fig. 3e) as well as E. coli septicemia secondary to a urinary tract infection. These infections were treated successfully with liposomal amphotericin B and piperacillin/tazobactam. Prior to lymphodepletion (D-5), the patient presented with an ECOG performance status of 1, intact renal and liver function, while observing residually depressed blood counts (WBC 1270/μl, ANC 700/μl, ALC 390/μl, Hemoglobin 7.2 g/dl, Platelets 20 G/l). BM histopathology showed a hypocellular marrow with no evidence of lymphoma infiltration. Analysis of lymphocyte subpopulations demonstrated severe B-cell aplasia and decreased absolute CD4+ (84/μl) and CD8+ (271/μl) counts. His anti-infective prophylaxis consisted of a combination of acyclovir, sulfamethoxazole/trimethoprim (TMP/SMZ), and posaconazole. The fludarabine/cyclophosphamide lympho-preparative regimen was applied on days − 5 to − 3 according to the provider’s protocol, followed by CAR T-cell transfusion on day 0.
Fig. 1 Overview of CAR T-cell mediated hematotoxicity and infectious complications. a Treatment course prior to CAR T-cell therapy. b Timeline of infectious complications during CAR T-cell treatment course. Positive microbiologic culture results are underlined. Bottom: Overview of utilized anti-infectives with the respective bars displaying the length of treatment. P/T = piperacillin/tazobactam, Ami = amikacin, Mero = meropenem, Vanco = vancomycin, Line = linezolid, Posa = posaconazole (p.o.), Mica = micafungin (i.v.), Amb = liposomal amphotericin B. The patient also received prophylactic acyclovir and sulfamethoxazole/trimethoprim (TMP/SMZ) during treatment. c Complete Blood Count (CBC) timeline. ANC (blue), platelet count (green), Hemoglobin (red). Transfusion events (green: platelet transfusion, red: pRBC transfusion) and G-CSF support (blue bar) are integrated in the curve. d Dynamics of Serum Inflammatory Markers. Infectious complications are superimposed above the graph. e Histopathologic analysis of BM biopsies demonstrating severe BM aplasia 1 month after CAR T-cell transfusion (Day 32, upper panel) and evidence of recovering hematopoiesis following autologous stem cell transfer (Autopsy, lower panel). Immunohistochemical staining for myeloperoxidase (= MPO) highlighting strong activation of myelopoiesis (right panel)
Fig. 2 Radiographic evidence of partial response to Axi-cel after 36 days. Contrast-enhanced CT abdomen (axial view) displaying pleural manifestations before (a) and after (b) CAR T-cell treatment. Involved paraaortic lymph nodes (red arrows) demonstrate an interval decrease in size (c-d, e-f). The inset of panel F depicts splenic hypodensities consistent with necrosis of tumor tissue secondary to immune therapy and a reduction of splenomegaly. G Graphical depiction of response over time. Tumor extent was quantified as the sum of the product of perpendicular diameters according to Lugano criteria over 3 time points and is graphed on the y-axis. H Timeline of LDH levels (U/l). The increase in LDH levels at day 25 correlated with the gastrointestinal toxicity and liver dysfunction
Fig. 3 Multi-organ toxicity secondary to CD19-directed CAR T-cell therapy. a Contrast-enhanced CT abdomen demonstrating a non-inflamed baseline state of GI mucosal tissue prior to CAR T therapy. b Panmural swelling of the sigma (left panel), ascending colon (middle panel), and stomach. c Non-pathologic CT of the brain. d Axial FLAIR-weighted (left), T1-weighted contrast-enhanced (middle), and diffusion-weighted (right) MRI displaying no evidence of cerebral edema, white matter lesions, diffusion restriction, microbleeds, meningeal enhancement or contrast enhancing lesions. e High-resolution CT thorax with bilateral fungal infiltrates observing the typical halo configuration 6 weeks prior to CAR T-cell transfusion. f On day − 3 the right-sided infiltrates have decreased in size. The left lung is collapsed due to malignant pleural effusion. g Lung parenchyma exhibiting an infiltration of non-dimorphic blastoconidial morphology consistent with Candida glabrata. h PAS staining of a lung specimen highlights septated hiphae and acute-angle branching, features consistent of with aspergillus infection
During lymphodepletion the patient developed an upper respiratory infection, presenting with a non-productive cough and a sputum culture positive for Bordetella bronchiseptica, which resolved clinically after antibiotic treatment with piperacillin/tazobactam. On day 7, the patient developed fever with a stable cardiopulmonary function and concomitant IL-6 rise (Fig. 1d), which was classified as CRS grade I according to ASTCT consensus grading [7] in the absence of positive blood cultures and other foci. Due to persistent fever refractory to antipyretic treatment, four total doses of tocilizumab (8 mg/kg) were applied over 36 h. Starting on day 9, the patient deteriorated neurologically with a depressed state of consciousness prompting the diagnosis of grade IV ICANS. The patient was transferred to the neurological ICU, and high-dose corticosteroids (methylprednisolone 1000 mg daily) were initiated. CSF-analysis displayed subtle pleocytosis, but revealed no signs of CNS infection (viral, bacterial and fungal) or meningeal involvement of the DLBCL. CT and MR imaging of the brain exhibited none of the pathological findings reported for ICANS [8] or CNS infection [9](Fig. 3c-d). After 5 days of high-dose methylprednisolone, the patient’s neurological status slowly improved, and corticosteroids could be tapered.
Partial response to Axicabtagene-Ciloleucel after 36 days according to Lugano criteria
While the patient’s initial clinical course was fraught with complications, CT staging performed at day 36 demonstrated a partial response to CAR T-cell therapy according to Lugano and Lyric criteria (Fig. 2a-g). This was particularly evident for the pleural manifestations of the underlying DLBCL, which was accompanied by an interval decrease in pleural effusions and subjective dyspnea (Fig. 2a-b). Multiple nodal sites including paraaortic (Fig. 2c-d) and parailiac lymph nodes (Fig. 2e-f) exhibited significant regression of tumor size (Fig. 2g). Moreover, the patient displayed splenic hypodensities consistent with either tumor tissue necrosis or infection-associated inflammatory changes (inset, Fig. 2f). These CT-morphologic findings were accompanied by a decrease of LDH levels (Fig. 2h).
Prolonged cytopenia lead to the development of severe neutropenic colitis and fatal fungal pneumonia
The patient presented with significant myelotoxicity and sustained transfusion dependency after CAR T-cell administration (Fig. 1c). The overall duration of profound neutropenia – defined as an ANC < 100/μl [10] – was 52 days. Because of the severity of ICANS, the clinicians chose to hold G-CSF during this time period due to concerns for risk of worsening toxicity [11].
While receiving broad anti-infectives (acyclovir, TMP/SMZ, posaconazole, meropenem), the patient developed breakthrough septic shock on day 24. He exhibited fever (39.5 °C), hypotension (70/30 mmHg), tachycardia (160/min), as well as lactic acidosis (lactate: 10.7 mmol/l). The patient was non-conversant, non-oriented, and was not able to localize symptoms. However, he had described epigastric tenderness and subtle changes in stool consistency and frequency on the previous day. As a result, abdominal CT imaging was obtained, which displayed severe pancolitis, as evidenced by pronounced mucosal thickening with edematous changes ranging from the ascending colon to the rectum (Fig. 3a-b). Labs were notable for an acute spike of serum inflammatory parameters (Il-6 > 500.000 pg/ml, CRP 5.7 mg/dl, Procalcitonin 11.2 ng/ml, Fig. 1d). Following ICU transfer, high-dose vasopressor support with norepinephrine was initiated together with volume resuscitation to maintain organ perfusion. Due to progressive loss of consciousness the patient was intubated and mechanically ventilated. To control the proinflammatory state, extracorporeal cytokine absorption (Cytosorb®) was performed, which resulted in a decrease of soluble inflammatory markers in the subsequent days. Arterial blood cultures were positive for vancomycin-resistant enterococci (VRE), and the antibiotic treatment was escalated to include linezolid along with meropenem (Fig. 1b). The ICU team transitioned antifungal prophylaxis from posaconazole to an echinocandine (micafungin 50 mg IV) due to ECG changes and concerns for drug interactions on day 24. Though he remained in critical condition, in the coming weeks his clinical condition stabilized and both the catecholamine rate and volume support could be reduced. To determine the origin of sustained myelosuppression, a bone marrow biopsy was obtained, which depicted a hypocellular marrow and severe aplasia affecting all hematopoietic lineages (Fig. 1e). On days 41 and 49, surveillance blood cultures were positive for Candida glabrata, a commensal fungal organism of human mucosal tissues [12] harboring an intrinsic azole resistance [13]. Susceptibility testing confirmed the azole-resistance of C. glabrata isolates. The antimycotic therapy was escalated from micafungin to liposomal amphotericin B. C. glabrata likely disseminated to the bloodstream secondary to the described gastrointestinal toxicity and was previously discovered on rectal swab (Fig. 1b) and fecal culture (day − 51).
Due to sustained neutropenia, BM aplasia and the availability of a suitable apheresis product, the CAR T-cell Taskforce proceeded with a stem cell boost of previously collected autologous CD34+ cells (3,1 × 106 cells) on day 46. The combination of a sudden rise in serum inflammatory markers and a strongly positive serum galactomannan (GM) assay on day 49 prompted diagnostic bronchoscopy, which revealed a diffuse infiltrate of alveolar and peri-bronchial tissue by Aspergillus fumigatus, consistent with fulminant invasive fungal pneumonia. Over the next week, the patient became increasingly hemodynamically unstable with poor peripheral oxygenation. Repeat bronchoscopy with bronchial lavage was positive for A. fumigatus and C. glabrata. After 50 days of G-CSF refractory aplasia, the autologous stem cells slowly engrafted leading to neutrophil recovery. However, this likely exacerbated the local inflammatory reaction in the lung, contributing to rapid deterioration of his respiratory status. Despite extensive supportive measures, the patient died on day 58 after CAR T-cell transfusion. Cause of death was confirmed by autopsy as invasive fungal pneumonia with multi-organ septic spread. Post-mortem examination revealed Candida spores in intestinal, colonic and rectal tissue. Of note, histopathologic BM analysis revealed signs of burgeoning hematopoietic regeneration (Fig. 1e).
Discussion and conclusions
Recent studies have shed light on the high incidence of prolonged and profound neutropenia after adoptive immunotherapy with CD19-specific CAR T-cells [1–3]. Clinical sequalae include severe infectious complications, which have emerged as the number one cause of long-term non-relapse mortality after CAR T-cell therapy [14]. In a seminal study, Hill and colleagues demonstrate that infectious complications are common with a cumulative incidence of 23% in the first 28 days after CAR T-cell transfusion and 14% between days 29–90. While bacterial infections were most common in the first month, viral infections – especially respiratory viruses – predominated after day 29, likely as a result of an impaired adaptive immune response due to B-cell aplasia [15]. Overall, most infections were mild to moderate and fatal infections were rare. Invasive mold infections were uncommon, ranging from 1 to 7% in CAR T-cell recipients [15–17]. In multivariate analyses, the use of systemic corticosteroids for the management of CRS or ICANS has emerged as a major risk factor of infection [18]. Certain inflammatory signatures – such as the “double peaks of IL-6” pattern observed in our patient – have been shown to confer an especially high risk of life-threatening infection [19].
This case highlights the combination of factors that precipitate a high risk of infectious complications in a CAR T-cell patient. First, the heavily pre-treated patient displayed B-cell aplasia and a diminished hematopoietic reserve (e.g. trilineage cytopenia) prior to lymphodepletion. Second, the patient developed classic complications of CAR T-cell therapy such as CRS and severe and prolonged ICANS, reflecting a pro-inflammatory state that represents an important risk factor for developing infections in CAR T-cell patients [16]. The subsequent application of high-dose corticosteroids impaired both innate and adaptive immunity [20]. Third, pancytopenia was profound, prolonged and not able to be reverted by growth factor support. Fourth, the patient had a history of infectious complications, including a course of fungal pneumonia 6 weeks prior to lymphodepletion, likely flaring up in the setting of the above three factors.
Our patient developed severe septic shock secondary to neutropenic colitis on day 24, highlighting the risk of a watch-and-wait approach to prolonged neutropenia after CAR T-cell therapy. A two-pronged approach to management appears prescient. On the one hand, measures to propagate hematopoietic recovery should be exhausted (causal therapy). This can range from G-CSF stimulation, to a trial of pulse-dose corticosteroids or anti-cytokine therapy (e.g. Anakinra, Tocilizumab), to a stem cell boost as a last resort in lymphoma patients who have undergone prior autologous stem cell transplantation. On the other hand, clinicians should be at high alert for infectious complications and adapt their infection surveillance and anti-infective prophylactic strategies accordingly. For example, therapeutic drug monitoring of posaconazole and meropenem levels may have revealed subtherapeutic dosing of these anti-infective agents in this patient [21]. The role of antifungal prophylaxis in the CAR T-cell patient remains inconclusive. Adequately powered studies addressing the duration of neutropenia after CAR T-cell therapy, and potential clinical determinants of invasive fungal infections, will be critical to gauge the benefit of antifungal prophylaxis in this patient collective.
Candida species are a leading cause of fungus-associated morbidity and mortality in severely immunocompromised patients [21]. On day 41, this patient developed breakthrough C. glabrata Candidemia on micafungin, in the setting of both underlying colonization and neutropenic colitis. A recent report implicated the gastrointestinal tract as major source of echinocandin drug resistance in a murine model of C. glabrata colonization and systemic dissemination [22]. Of note, breakthrough Candida infections on micafungin may occur at the employed dose level (50 mg/day IV), suggesting that this dose may have been inadequate to prevent subsequent Candidemia [23]. Though cases of C. glabrata colitis are extremely rare [24], an opportunistic infection could not be ruled out given that C. glabrata infiltrates were discovered in enteral and colonic mucosal tissue on post-mortem examination. Importantly, the patients’ clinical status deteriorated only after the stem cell boost resulted in signs of hematopoietic recovery. The paradoxical worsening of the pulmonary A. fumigatus infection is consistent with immune reconstitution inflammatory syndrome (IRIS), which has been previously described for HIV/AIDS [25] and for severely neutropenic patients with IPA [26]. In conclusion, this case emphasizes that infectious complications secondary to prolonged cytopenia influence non-relapse mortality after CAR T-cell therapy.
Abbreviations
ALCAbsolute Lymphocyte Count
ANCAbsolute Neutrophil Count
BMBone Marrow
CARChimeric antigen receptor
CBCComplete Blood Count
CRSCytokine release syndrome
CTCAECommon Terminology Criteria for Adverse Events
DLBCLDiffuse large B-cell lymphoma
FFPFresh frozen plasma
FLAIRFluid-attenuated inversion recovery
Flu/CyFludarabine/Cyclophosphamide
G-CSFGranulocyte colony stimulating factor
GIGastrointestinal
GMGalactomannan
HSPCsHematopoietic stem and progenitor cells
ICANSImmune effector cell-associated neurotoxicity syndrome
ICE-scoreImmune Effector Cell-associated Encephalopathy score
ICUIntensive care unit
IPAInvasive pulmonary aspergillosis
LDHLactate Dehydrogenase
LYRICLymphoma response to immunomodulatory therapy criteria
MDRDModification of Diet in Renal Disease
MPOMyeloperoxidase
PASPeriodic acid-Schiff
PBSCPeripheral Blood Stem Cell
VREVancomycin-resistant Enterococcus
WBCWhite Blood Count
Publisher’s Note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
Acknowledgements
Not applicable.
Authors’ contributions
The original manuscript was written by KR. KR and WGK prepared the figures. MR performed the histological examination of the bone marrow. MS reviewed and edited the manuscript. The other authors (VB1, VB2, CS, PK, FS, KD, LvB, JS, OW, MD, MvBB) contributed to patient management and participated in drafting and editing the manuscript. All authors read and approved the final manuscript.
Funding
Not applicable. Open Access funding enabled and organized by Projekt DEAL.
Availability of data and materials
The authors did not use any database, software, or tools for the writing of this manuscript.
Ethics approval and consent to participate
The authors obtained consent from the deceased patient’s next-of-kin to participate.
Consent for publication
Written informed consent was obtained from the patient’s next-of-kin for publication of this Case report and any accompanying images. A copy of the written consent is available for review by the Editor of this journal.
Competing interests
The authors declare that they have no competing interests related with this case report. | CYCLOPHOSPHAMIDE, DOXORUBICIN HYDROCHLORIDE, METHYLPREDNISOLONE, PREDNISOLONE, RITUXIMAB, VINCRISTINE | DrugsGivenReaction | CC BY | 33509115 | 18,947,434 | 2021-01-28 |
Give an alphabetized list of all active substances of drugs taken by the patient who experienced 'Enterococcal infection'. | Severe Candida glabrata pancolitis and fatal Aspergillus fumigatus pulmonary infection in the setting of bone marrow aplasia after CD19-directed CAR T-cell therapy - a case report.
BACKGROUND
Prolonged myelosuppression following CD19-directed CAR T-cell transfusion represents an important, yet underreported, adverse event. The resulting neutropenia and multifactorial immunosuppression can facilitate severe infectious complications.
METHODS
We describe the clinical course of a 59-year-old patient with relapsed/refractory DLBCL who received Axicabtagene-Ciloleucel (Axi-cel). The patient developed ASTCT grade I CRS and grade IV ICANS, necessitating admission to the neurological ICU and prolonged application of high-dose corticosteroids and other immunosuppressive agents. Importantly, neutropenia was profound (ANC < 100/μl), G-CSF-refractory, and prolonged, lasting more than 50 days. The patient developed severe septic shock 3 weeks after CAR transfusion while receiving anti-fungal prophylaxis with micafungin. His clinical status stabilized with broad anti-infective treatment and intensive supportive measures. An autologous stem cell backup was employed on day 46 to support hematopoietic recovery. Although the counts of the patient eventually started to recover, he developed an invasive pulmonary aspergillosis, which ultimately lead to respiratory failure and death. Postmortem examination revealed signs of Candida glabrata pancolitis.
CONCLUSIONS
This case highlights the increased risk for fatal infectious complications in patients who present with profound and prolonged cytopenia after CAR T-cell therapy. We describe a rare case of C. glabrata pancolitis associated with multifactorial immunosuppression. Although our patient succumbed to a fatal fungal infection, autologous stem cell boost was able to spur hematopoiesis and may represent an important therapeutic strategy for DLBCL patients with CAR T-cell associated bone marrow aplasia who have underwent prior stem cell harvest.
Background
When CD19-directed Chimeric Antigen Receptor (CAR) T-cell therapies were first introduced into the clinical setting, a set of distinctive side effects were observed, including Cytokine Release Syndrome (CRS) and immune effector cell-associated neurotoxicity syndrome (ICANS). As these treatments transition from large clinical trials to real-world implementation, new nuances of the side effect spectrum have emerged. This includes the observation that patients can present not only with grade 3–4 cytopenia (CTCAE v5.0), but also a syndrome of persistent cytopenia after CAR T-cell transfusion [1, 2]. Hematologic toxicity is common with one study demonstrating that neutropenia, thrombocytopenia and anemia occur in 94, 80 and 51% of patients respectively [3]. Risk factors for hematotoxicity include CRS grade, baseline cytopenia, and prior allogeneic stem cell transplantation within the last year [2, 3]. The fact that baseline hematopoietic reserve contributes to cytopenia in CAR T-cell patients may explain the variability in the incidence of hematoxicity in the real-world setting compared to the large registration trials, which set stringent hematologic exclusion criteria [4, 5]. The clinical utility of therapeutic rescue strategies that mitigate the risk of infectious complications secondary to long-term bone marrow (BM) aplasia, such as early autologous stem cell boost or Eltrombopag, remains unknown. Moreover, the relative paucity of reports concerning severe and life-threatening infections in the reported CD19-directed CAR T-cell trials necessitates the presentation of distinctive clinical courses that underline the risks of persistent cytopenia after CAR T-cell therapy in a real-world setting.
Case presentation
The 59-year-old male patient was initially diagnosed with stage IIIA follicular lymphoma in January 2018, which transformed to germinal center B-cell like DLBCL in October of the same year. Refractory to multiple cycles of Rituximab-based immunochemotherapy (Fig. 1a), the patient underwent leukapheresis for CAR T-cell therapy in April 2019. The patient experienced significant lymphoma progression during the manufacturing process of Axicabtagene ciloleucel (Axi-cel), manifesting itself in the form of malignant pleural effusions and progressive lymphadenopathy (Fig. 2a,c,e). In the six-week period between leukapheresis and lymphodepletion, the patient remained severely neutropenic after R-CHOP and developed possible invasive fungal disease (IFD) [6] (Fig. 3e) as well as E. coli septicemia secondary to a urinary tract infection. These infections were treated successfully with liposomal amphotericin B and piperacillin/tazobactam. Prior to lymphodepletion (D-5), the patient presented with an ECOG performance status of 1, intact renal and liver function, while observing residually depressed blood counts (WBC 1270/μl, ANC 700/μl, ALC 390/μl, Hemoglobin 7.2 g/dl, Platelets 20 G/l). BM histopathology showed a hypocellular marrow with no evidence of lymphoma infiltration. Analysis of lymphocyte subpopulations demonstrated severe B-cell aplasia and decreased absolute CD4+ (84/μl) and CD8+ (271/μl) counts. His anti-infective prophylaxis consisted of a combination of acyclovir, sulfamethoxazole/trimethoprim (TMP/SMZ), and posaconazole. The fludarabine/cyclophosphamide lympho-preparative regimen was applied on days − 5 to − 3 according to the provider’s protocol, followed by CAR T-cell transfusion on day 0.
Fig. 1 Overview of CAR T-cell mediated hematotoxicity and infectious complications. a Treatment course prior to CAR T-cell therapy. b Timeline of infectious complications during CAR T-cell treatment course. Positive microbiologic culture results are underlined. Bottom: Overview of utilized anti-infectives with the respective bars displaying the length of treatment. P/T = piperacillin/tazobactam, Ami = amikacin, Mero = meropenem, Vanco = vancomycin, Line = linezolid, Posa = posaconazole (p.o.), Mica = micafungin (i.v.), Amb = liposomal amphotericin B. The patient also received prophylactic acyclovir and sulfamethoxazole/trimethoprim (TMP/SMZ) during treatment. c Complete Blood Count (CBC) timeline. ANC (blue), platelet count (green), Hemoglobin (red). Transfusion events (green: platelet transfusion, red: pRBC transfusion) and G-CSF support (blue bar) are integrated in the curve. d Dynamics of Serum Inflammatory Markers. Infectious complications are superimposed above the graph. e Histopathologic analysis of BM biopsies demonstrating severe BM aplasia 1 month after CAR T-cell transfusion (Day 32, upper panel) and evidence of recovering hematopoiesis following autologous stem cell transfer (Autopsy, lower panel). Immunohistochemical staining for myeloperoxidase (= MPO) highlighting strong activation of myelopoiesis (right panel)
Fig. 2 Radiographic evidence of partial response to Axi-cel after 36 days. Contrast-enhanced CT abdomen (axial view) displaying pleural manifestations before (a) and after (b) CAR T-cell treatment. Involved paraaortic lymph nodes (red arrows) demonstrate an interval decrease in size (c-d, e-f). The inset of panel F depicts splenic hypodensities consistent with necrosis of tumor tissue secondary to immune therapy and a reduction of splenomegaly. G Graphical depiction of response over time. Tumor extent was quantified as the sum of the product of perpendicular diameters according to Lugano criteria over 3 time points and is graphed on the y-axis. H Timeline of LDH levels (U/l). The increase in LDH levels at day 25 correlated with the gastrointestinal toxicity and liver dysfunction
Fig. 3 Multi-organ toxicity secondary to CD19-directed CAR T-cell therapy. a Contrast-enhanced CT abdomen demonstrating a non-inflamed baseline state of GI mucosal tissue prior to CAR T therapy. b Panmural swelling of the sigma (left panel), ascending colon (middle panel), and stomach. c Non-pathologic CT of the brain. d Axial FLAIR-weighted (left), T1-weighted contrast-enhanced (middle), and diffusion-weighted (right) MRI displaying no evidence of cerebral edema, white matter lesions, diffusion restriction, microbleeds, meningeal enhancement or contrast enhancing lesions. e High-resolution CT thorax with bilateral fungal infiltrates observing the typical halo configuration 6 weeks prior to CAR T-cell transfusion. f On day − 3 the right-sided infiltrates have decreased in size. The left lung is collapsed due to malignant pleural effusion. g Lung parenchyma exhibiting an infiltration of non-dimorphic blastoconidial morphology consistent with Candida glabrata. h PAS staining of a lung specimen highlights septated hiphae and acute-angle branching, features consistent of with aspergillus infection
During lymphodepletion the patient developed an upper respiratory infection, presenting with a non-productive cough and a sputum culture positive for Bordetella bronchiseptica, which resolved clinically after antibiotic treatment with piperacillin/tazobactam. On day 7, the patient developed fever with a stable cardiopulmonary function and concomitant IL-6 rise (Fig. 1d), which was classified as CRS grade I according to ASTCT consensus grading [7] in the absence of positive blood cultures and other foci. Due to persistent fever refractory to antipyretic treatment, four total doses of tocilizumab (8 mg/kg) were applied over 36 h. Starting on day 9, the patient deteriorated neurologically with a depressed state of consciousness prompting the diagnosis of grade IV ICANS. The patient was transferred to the neurological ICU, and high-dose corticosteroids (methylprednisolone 1000 mg daily) were initiated. CSF-analysis displayed subtle pleocytosis, but revealed no signs of CNS infection (viral, bacterial and fungal) or meningeal involvement of the DLBCL. CT and MR imaging of the brain exhibited none of the pathological findings reported for ICANS [8] or CNS infection [9](Fig. 3c-d). After 5 days of high-dose methylprednisolone, the patient’s neurological status slowly improved, and corticosteroids could be tapered.
Partial response to Axicabtagene-Ciloleucel after 36 days according to Lugano criteria
While the patient’s initial clinical course was fraught with complications, CT staging performed at day 36 demonstrated a partial response to CAR T-cell therapy according to Lugano and Lyric criteria (Fig. 2a-g). This was particularly evident for the pleural manifestations of the underlying DLBCL, which was accompanied by an interval decrease in pleural effusions and subjective dyspnea (Fig. 2a-b). Multiple nodal sites including paraaortic (Fig. 2c-d) and parailiac lymph nodes (Fig. 2e-f) exhibited significant regression of tumor size (Fig. 2g). Moreover, the patient displayed splenic hypodensities consistent with either tumor tissue necrosis or infection-associated inflammatory changes (inset, Fig. 2f). These CT-morphologic findings were accompanied by a decrease of LDH levels (Fig. 2h).
Prolonged cytopenia lead to the development of severe neutropenic colitis and fatal fungal pneumonia
The patient presented with significant myelotoxicity and sustained transfusion dependency after CAR T-cell administration (Fig. 1c). The overall duration of profound neutropenia – defined as an ANC < 100/μl [10] – was 52 days. Because of the severity of ICANS, the clinicians chose to hold G-CSF during this time period due to concerns for risk of worsening toxicity [11].
While receiving broad anti-infectives (acyclovir, TMP/SMZ, posaconazole, meropenem), the patient developed breakthrough septic shock on day 24. He exhibited fever (39.5 °C), hypotension (70/30 mmHg), tachycardia (160/min), as well as lactic acidosis (lactate: 10.7 mmol/l). The patient was non-conversant, non-oriented, and was not able to localize symptoms. However, he had described epigastric tenderness and subtle changes in stool consistency and frequency on the previous day. As a result, abdominal CT imaging was obtained, which displayed severe pancolitis, as evidenced by pronounced mucosal thickening with edematous changes ranging from the ascending colon to the rectum (Fig. 3a-b). Labs were notable for an acute spike of serum inflammatory parameters (Il-6 > 500.000 pg/ml, CRP 5.7 mg/dl, Procalcitonin 11.2 ng/ml, Fig. 1d). Following ICU transfer, high-dose vasopressor support with norepinephrine was initiated together with volume resuscitation to maintain organ perfusion. Due to progressive loss of consciousness the patient was intubated and mechanically ventilated. To control the proinflammatory state, extracorporeal cytokine absorption (Cytosorb®) was performed, which resulted in a decrease of soluble inflammatory markers in the subsequent days. Arterial blood cultures were positive for vancomycin-resistant enterococci (VRE), and the antibiotic treatment was escalated to include linezolid along with meropenem (Fig. 1b). The ICU team transitioned antifungal prophylaxis from posaconazole to an echinocandine (micafungin 50 mg IV) due to ECG changes and concerns for drug interactions on day 24. Though he remained in critical condition, in the coming weeks his clinical condition stabilized and both the catecholamine rate and volume support could be reduced. To determine the origin of sustained myelosuppression, a bone marrow biopsy was obtained, which depicted a hypocellular marrow and severe aplasia affecting all hematopoietic lineages (Fig. 1e). On days 41 and 49, surveillance blood cultures were positive for Candida glabrata, a commensal fungal organism of human mucosal tissues [12] harboring an intrinsic azole resistance [13]. Susceptibility testing confirmed the azole-resistance of C. glabrata isolates. The antimycotic therapy was escalated from micafungin to liposomal amphotericin B. C. glabrata likely disseminated to the bloodstream secondary to the described gastrointestinal toxicity and was previously discovered on rectal swab (Fig. 1b) and fecal culture (day − 51).
Due to sustained neutropenia, BM aplasia and the availability of a suitable apheresis product, the CAR T-cell Taskforce proceeded with a stem cell boost of previously collected autologous CD34+ cells (3,1 × 106 cells) on day 46. The combination of a sudden rise in serum inflammatory markers and a strongly positive serum galactomannan (GM) assay on day 49 prompted diagnostic bronchoscopy, which revealed a diffuse infiltrate of alveolar and peri-bronchial tissue by Aspergillus fumigatus, consistent with fulminant invasive fungal pneumonia. Over the next week, the patient became increasingly hemodynamically unstable with poor peripheral oxygenation. Repeat bronchoscopy with bronchial lavage was positive for A. fumigatus and C. glabrata. After 50 days of G-CSF refractory aplasia, the autologous stem cells slowly engrafted leading to neutrophil recovery. However, this likely exacerbated the local inflammatory reaction in the lung, contributing to rapid deterioration of his respiratory status. Despite extensive supportive measures, the patient died on day 58 after CAR T-cell transfusion. Cause of death was confirmed by autopsy as invasive fungal pneumonia with multi-organ septic spread. Post-mortem examination revealed Candida spores in intestinal, colonic and rectal tissue. Of note, histopathologic BM analysis revealed signs of burgeoning hematopoietic regeneration (Fig. 1e).
Discussion and conclusions
Recent studies have shed light on the high incidence of prolonged and profound neutropenia after adoptive immunotherapy with CD19-specific CAR T-cells [1–3]. Clinical sequalae include severe infectious complications, which have emerged as the number one cause of long-term non-relapse mortality after CAR T-cell therapy [14]. In a seminal study, Hill and colleagues demonstrate that infectious complications are common with a cumulative incidence of 23% in the first 28 days after CAR T-cell transfusion and 14% between days 29–90. While bacterial infections were most common in the first month, viral infections – especially respiratory viruses – predominated after day 29, likely as a result of an impaired adaptive immune response due to B-cell aplasia [15]. Overall, most infections were mild to moderate and fatal infections were rare. Invasive mold infections were uncommon, ranging from 1 to 7% in CAR T-cell recipients [15–17]. In multivariate analyses, the use of systemic corticosteroids for the management of CRS or ICANS has emerged as a major risk factor of infection [18]. Certain inflammatory signatures – such as the “double peaks of IL-6” pattern observed in our patient – have been shown to confer an especially high risk of life-threatening infection [19].
This case highlights the combination of factors that precipitate a high risk of infectious complications in a CAR T-cell patient. First, the heavily pre-treated patient displayed B-cell aplasia and a diminished hematopoietic reserve (e.g. trilineage cytopenia) prior to lymphodepletion. Second, the patient developed classic complications of CAR T-cell therapy such as CRS and severe and prolonged ICANS, reflecting a pro-inflammatory state that represents an important risk factor for developing infections in CAR T-cell patients [16]. The subsequent application of high-dose corticosteroids impaired both innate and adaptive immunity [20]. Third, pancytopenia was profound, prolonged and not able to be reverted by growth factor support. Fourth, the patient had a history of infectious complications, including a course of fungal pneumonia 6 weeks prior to lymphodepletion, likely flaring up in the setting of the above three factors.
Our patient developed severe septic shock secondary to neutropenic colitis on day 24, highlighting the risk of a watch-and-wait approach to prolonged neutropenia after CAR T-cell therapy. A two-pronged approach to management appears prescient. On the one hand, measures to propagate hematopoietic recovery should be exhausted (causal therapy). This can range from G-CSF stimulation, to a trial of pulse-dose corticosteroids or anti-cytokine therapy (e.g. Anakinra, Tocilizumab), to a stem cell boost as a last resort in lymphoma patients who have undergone prior autologous stem cell transplantation. On the other hand, clinicians should be at high alert for infectious complications and adapt their infection surveillance and anti-infective prophylactic strategies accordingly. For example, therapeutic drug monitoring of posaconazole and meropenem levels may have revealed subtherapeutic dosing of these anti-infective agents in this patient [21]. The role of antifungal prophylaxis in the CAR T-cell patient remains inconclusive. Adequately powered studies addressing the duration of neutropenia after CAR T-cell therapy, and potential clinical determinants of invasive fungal infections, will be critical to gauge the benefit of antifungal prophylaxis in this patient collective.
Candida species are a leading cause of fungus-associated morbidity and mortality in severely immunocompromised patients [21]. On day 41, this patient developed breakthrough C. glabrata Candidemia on micafungin, in the setting of both underlying colonization and neutropenic colitis. A recent report implicated the gastrointestinal tract as major source of echinocandin drug resistance in a murine model of C. glabrata colonization and systemic dissemination [22]. Of note, breakthrough Candida infections on micafungin may occur at the employed dose level (50 mg/day IV), suggesting that this dose may have been inadequate to prevent subsequent Candidemia [23]. Though cases of C. glabrata colitis are extremely rare [24], an opportunistic infection could not be ruled out given that C. glabrata infiltrates were discovered in enteral and colonic mucosal tissue on post-mortem examination. Importantly, the patients’ clinical status deteriorated only after the stem cell boost resulted in signs of hematopoietic recovery. The paradoxical worsening of the pulmonary A. fumigatus infection is consistent with immune reconstitution inflammatory syndrome (IRIS), which has been previously described for HIV/AIDS [25] and for severely neutropenic patients with IPA [26]. In conclusion, this case emphasizes that infectious complications secondary to prolonged cytopenia influence non-relapse mortality after CAR T-cell therapy.
Abbreviations
ALCAbsolute Lymphocyte Count
ANCAbsolute Neutrophil Count
BMBone Marrow
CARChimeric antigen receptor
CBCComplete Blood Count
CRSCytokine release syndrome
CTCAECommon Terminology Criteria for Adverse Events
DLBCLDiffuse large B-cell lymphoma
FFPFresh frozen plasma
FLAIRFluid-attenuated inversion recovery
Flu/CyFludarabine/Cyclophosphamide
G-CSFGranulocyte colony stimulating factor
GIGastrointestinal
GMGalactomannan
HSPCsHematopoietic stem and progenitor cells
ICANSImmune effector cell-associated neurotoxicity syndrome
ICE-scoreImmune Effector Cell-associated Encephalopathy score
ICUIntensive care unit
IPAInvasive pulmonary aspergillosis
LDHLactate Dehydrogenase
LYRICLymphoma response to immunomodulatory therapy criteria
MDRDModification of Diet in Renal Disease
MPOMyeloperoxidase
PASPeriodic acid-Schiff
PBSCPeripheral Blood Stem Cell
VREVancomycin-resistant Enterococcus
WBCWhite Blood Count
Publisher’s Note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
Acknowledgements
Not applicable.
Authors’ contributions
The original manuscript was written by KR. KR and WGK prepared the figures. MR performed the histological examination of the bone marrow. MS reviewed and edited the manuscript. The other authors (VB1, VB2, CS, PK, FS, KD, LvB, JS, OW, MD, MvBB) contributed to patient management and participated in drafting and editing the manuscript. All authors read and approved the final manuscript.
Funding
Not applicable. Open Access funding enabled and organized by Projekt DEAL.
Availability of data and materials
The authors did not use any database, software, or tools for the writing of this manuscript.
Ethics approval and consent to participate
The authors obtained consent from the deceased patient’s next-of-kin to participate.
Consent for publication
Written informed consent was obtained from the patient’s next-of-kin for publication of this Case report and any accompanying images. A copy of the written consent is available for review by the Editor of this journal.
Competing interests
The authors declare that they have no competing interests related with this case report. | CYCLOPHOSPHAMIDE, DOXORUBICIN HYDROCHLORIDE, METHYLPREDNISOLONE, PREDNISOLONE, RITUXIMAB, VINCRISTINE | DrugsGivenReaction | CC BY | 33509115 | 18,947,434 | 2021-01-28 |
Give an alphabetized list of all active substances of drugs taken by the patient who experienced 'Escherichia sepsis'. | Severe Candida glabrata pancolitis and fatal Aspergillus fumigatus pulmonary infection in the setting of bone marrow aplasia after CD19-directed CAR T-cell therapy - a case report.
BACKGROUND
Prolonged myelosuppression following CD19-directed CAR T-cell transfusion represents an important, yet underreported, adverse event. The resulting neutropenia and multifactorial immunosuppression can facilitate severe infectious complications.
METHODS
We describe the clinical course of a 59-year-old patient with relapsed/refractory DLBCL who received Axicabtagene-Ciloleucel (Axi-cel). The patient developed ASTCT grade I CRS and grade IV ICANS, necessitating admission to the neurological ICU and prolonged application of high-dose corticosteroids and other immunosuppressive agents. Importantly, neutropenia was profound (ANC < 100/μl), G-CSF-refractory, and prolonged, lasting more than 50 days. The patient developed severe septic shock 3 weeks after CAR transfusion while receiving anti-fungal prophylaxis with micafungin. His clinical status stabilized with broad anti-infective treatment and intensive supportive measures. An autologous stem cell backup was employed on day 46 to support hematopoietic recovery. Although the counts of the patient eventually started to recover, he developed an invasive pulmonary aspergillosis, which ultimately lead to respiratory failure and death. Postmortem examination revealed signs of Candida glabrata pancolitis.
CONCLUSIONS
This case highlights the increased risk for fatal infectious complications in patients who present with profound and prolonged cytopenia after CAR T-cell therapy. We describe a rare case of C. glabrata pancolitis associated with multifactorial immunosuppression. Although our patient succumbed to a fatal fungal infection, autologous stem cell boost was able to spur hematopoiesis and may represent an important therapeutic strategy for DLBCL patients with CAR T-cell associated bone marrow aplasia who have underwent prior stem cell harvest.
Background
When CD19-directed Chimeric Antigen Receptor (CAR) T-cell therapies were first introduced into the clinical setting, a set of distinctive side effects were observed, including Cytokine Release Syndrome (CRS) and immune effector cell-associated neurotoxicity syndrome (ICANS). As these treatments transition from large clinical trials to real-world implementation, new nuances of the side effect spectrum have emerged. This includes the observation that patients can present not only with grade 3–4 cytopenia (CTCAE v5.0), but also a syndrome of persistent cytopenia after CAR T-cell transfusion [1, 2]. Hematologic toxicity is common with one study demonstrating that neutropenia, thrombocytopenia and anemia occur in 94, 80 and 51% of patients respectively [3]. Risk factors for hematotoxicity include CRS grade, baseline cytopenia, and prior allogeneic stem cell transplantation within the last year [2, 3]. The fact that baseline hematopoietic reserve contributes to cytopenia in CAR T-cell patients may explain the variability in the incidence of hematoxicity in the real-world setting compared to the large registration trials, which set stringent hematologic exclusion criteria [4, 5]. The clinical utility of therapeutic rescue strategies that mitigate the risk of infectious complications secondary to long-term bone marrow (BM) aplasia, such as early autologous stem cell boost or Eltrombopag, remains unknown. Moreover, the relative paucity of reports concerning severe and life-threatening infections in the reported CD19-directed CAR T-cell trials necessitates the presentation of distinctive clinical courses that underline the risks of persistent cytopenia after CAR T-cell therapy in a real-world setting.
Case presentation
The 59-year-old male patient was initially diagnosed with stage IIIA follicular lymphoma in January 2018, which transformed to germinal center B-cell like DLBCL in October of the same year. Refractory to multiple cycles of Rituximab-based immunochemotherapy (Fig. 1a), the patient underwent leukapheresis for CAR T-cell therapy in April 2019. The patient experienced significant lymphoma progression during the manufacturing process of Axicabtagene ciloleucel (Axi-cel), manifesting itself in the form of malignant pleural effusions and progressive lymphadenopathy (Fig. 2a,c,e). In the six-week period between leukapheresis and lymphodepletion, the patient remained severely neutropenic after R-CHOP and developed possible invasive fungal disease (IFD) [6] (Fig. 3e) as well as E. coli septicemia secondary to a urinary tract infection. These infections were treated successfully with liposomal amphotericin B and piperacillin/tazobactam. Prior to lymphodepletion (D-5), the patient presented with an ECOG performance status of 1, intact renal and liver function, while observing residually depressed blood counts (WBC 1270/μl, ANC 700/μl, ALC 390/μl, Hemoglobin 7.2 g/dl, Platelets 20 G/l). BM histopathology showed a hypocellular marrow with no evidence of lymphoma infiltration. Analysis of lymphocyte subpopulations demonstrated severe B-cell aplasia and decreased absolute CD4+ (84/μl) and CD8+ (271/μl) counts. His anti-infective prophylaxis consisted of a combination of acyclovir, sulfamethoxazole/trimethoprim (TMP/SMZ), and posaconazole. The fludarabine/cyclophosphamide lympho-preparative regimen was applied on days − 5 to − 3 according to the provider’s protocol, followed by CAR T-cell transfusion on day 0.
Fig. 1 Overview of CAR T-cell mediated hematotoxicity and infectious complications. a Treatment course prior to CAR T-cell therapy. b Timeline of infectious complications during CAR T-cell treatment course. Positive microbiologic culture results are underlined. Bottom: Overview of utilized anti-infectives with the respective bars displaying the length of treatment. P/T = piperacillin/tazobactam, Ami = amikacin, Mero = meropenem, Vanco = vancomycin, Line = linezolid, Posa = posaconazole (p.o.), Mica = micafungin (i.v.), Amb = liposomal amphotericin B. The patient also received prophylactic acyclovir and sulfamethoxazole/trimethoprim (TMP/SMZ) during treatment. c Complete Blood Count (CBC) timeline. ANC (blue), platelet count (green), Hemoglobin (red). Transfusion events (green: platelet transfusion, red: pRBC transfusion) and G-CSF support (blue bar) are integrated in the curve. d Dynamics of Serum Inflammatory Markers. Infectious complications are superimposed above the graph. e Histopathologic analysis of BM biopsies demonstrating severe BM aplasia 1 month after CAR T-cell transfusion (Day 32, upper panel) and evidence of recovering hematopoiesis following autologous stem cell transfer (Autopsy, lower panel). Immunohistochemical staining for myeloperoxidase (= MPO) highlighting strong activation of myelopoiesis (right panel)
Fig. 2 Radiographic evidence of partial response to Axi-cel after 36 days. Contrast-enhanced CT abdomen (axial view) displaying pleural manifestations before (a) and after (b) CAR T-cell treatment. Involved paraaortic lymph nodes (red arrows) demonstrate an interval decrease in size (c-d, e-f). The inset of panel F depicts splenic hypodensities consistent with necrosis of tumor tissue secondary to immune therapy and a reduction of splenomegaly. G Graphical depiction of response over time. Tumor extent was quantified as the sum of the product of perpendicular diameters according to Lugano criteria over 3 time points and is graphed on the y-axis. H Timeline of LDH levels (U/l). The increase in LDH levels at day 25 correlated with the gastrointestinal toxicity and liver dysfunction
Fig. 3 Multi-organ toxicity secondary to CD19-directed CAR T-cell therapy. a Contrast-enhanced CT abdomen demonstrating a non-inflamed baseline state of GI mucosal tissue prior to CAR T therapy. b Panmural swelling of the sigma (left panel), ascending colon (middle panel), and stomach. c Non-pathologic CT of the brain. d Axial FLAIR-weighted (left), T1-weighted contrast-enhanced (middle), and diffusion-weighted (right) MRI displaying no evidence of cerebral edema, white matter lesions, diffusion restriction, microbleeds, meningeal enhancement or contrast enhancing lesions. e High-resolution CT thorax with bilateral fungal infiltrates observing the typical halo configuration 6 weeks prior to CAR T-cell transfusion. f On day − 3 the right-sided infiltrates have decreased in size. The left lung is collapsed due to malignant pleural effusion. g Lung parenchyma exhibiting an infiltration of non-dimorphic blastoconidial morphology consistent with Candida glabrata. h PAS staining of a lung specimen highlights septated hiphae and acute-angle branching, features consistent of with aspergillus infection
During lymphodepletion the patient developed an upper respiratory infection, presenting with a non-productive cough and a sputum culture positive for Bordetella bronchiseptica, which resolved clinically after antibiotic treatment with piperacillin/tazobactam. On day 7, the patient developed fever with a stable cardiopulmonary function and concomitant IL-6 rise (Fig. 1d), which was classified as CRS grade I according to ASTCT consensus grading [7] in the absence of positive blood cultures and other foci. Due to persistent fever refractory to antipyretic treatment, four total doses of tocilizumab (8 mg/kg) were applied over 36 h. Starting on day 9, the patient deteriorated neurologically with a depressed state of consciousness prompting the diagnosis of grade IV ICANS. The patient was transferred to the neurological ICU, and high-dose corticosteroids (methylprednisolone 1000 mg daily) were initiated. CSF-analysis displayed subtle pleocytosis, but revealed no signs of CNS infection (viral, bacterial and fungal) or meningeal involvement of the DLBCL. CT and MR imaging of the brain exhibited none of the pathological findings reported for ICANS [8] or CNS infection [9](Fig. 3c-d). After 5 days of high-dose methylprednisolone, the patient’s neurological status slowly improved, and corticosteroids could be tapered.
Partial response to Axicabtagene-Ciloleucel after 36 days according to Lugano criteria
While the patient’s initial clinical course was fraught with complications, CT staging performed at day 36 demonstrated a partial response to CAR T-cell therapy according to Lugano and Lyric criteria (Fig. 2a-g). This was particularly evident for the pleural manifestations of the underlying DLBCL, which was accompanied by an interval decrease in pleural effusions and subjective dyspnea (Fig. 2a-b). Multiple nodal sites including paraaortic (Fig. 2c-d) and parailiac lymph nodes (Fig. 2e-f) exhibited significant regression of tumor size (Fig. 2g). Moreover, the patient displayed splenic hypodensities consistent with either tumor tissue necrosis or infection-associated inflammatory changes (inset, Fig. 2f). These CT-morphologic findings were accompanied by a decrease of LDH levels (Fig. 2h).
Prolonged cytopenia lead to the development of severe neutropenic colitis and fatal fungal pneumonia
The patient presented with significant myelotoxicity and sustained transfusion dependency after CAR T-cell administration (Fig. 1c). The overall duration of profound neutropenia – defined as an ANC < 100/μl [10] – was 52 days. Because of the severity of ICANS, the clinicians chose to hold G-CSF during this time period due to concerns for risk of worsening toxicity [11].
While receiving broad anti-infectives (acyclovir, TMP/SMZ, posaconazole, meropenem), the patient developed breakthrough septic shock on day 24. He exhibited fever (39.5 °C), hypotension (70/30 mmHg), tachycardia (160/min), as well as lactic acidosis (lactate: 10.7 mmol/l). The patient was non-conversant, non-oriented, and was not able to localize symptoms. However, he had described epigastric tenderness and subtle changes in stool consistency and frequency on the previous day. As a result, abdominal CT imaging was obtained, which displayed severe pancolitis, as evidenced by pronounced mucosal thickening with edematous changes ranging from the ascending colon to the rectum (Fig. 3a-b). Labs were notable for an acute spike of serum inflammatory parameters (Il-6 > 500.000 pg/ml, CRP 5.7 mg/dl, Procalcitonin 11.2 ng/ml, Fig. 1d). Following ICU transfer, high-dose vasopressor support with norepinephrine was initiated together with volume resuscitation to maintain organ perfusion. Due to progressive loss of consciousness the patient was intubated and mechanically ventilated. To control the proinflammatory state, extracorporeal cytokine absorption (Cytosorb®) was performed, which resulted in a decrease of soluble inflammatory markers in the subsequent days. Arterial blood cultures were positive for vancomycin-resistant enterococci (VRE), and the antibiotic treatment was escalated to include linezolid along with meropenem (Fig. 1b). The ICU team transitioned antifungal prophylaxis from posaconazole to an echinocandine (micafungin 50 mg IV) due to ECG changes and concerns for drug interactions on day 24. Though he remained in critical condition, in the coming weeks his clinical condition stabilized and both the catecholamine rate and volume support could be reduced. To determine the origin of sustained myelosuppression, a bone marrow biopsy was obtained, which depicted a hypocellular marrow and severe aplasia affecting all hematopoietic lineages (Fig. 1e). On days 41 and 49, surveillance blood cultures were positive for Candida glabrata, a commensal fungal organism of human mucosal tissues [12] harboring an intrinsic azole resistance [13]. Susceptibility testing confirmed the azole-resistance of C. glabrata isolates. The antimycotic therapy was escalated from micafungin to liposomal amphotericin B. C. glabrata likely disseminated to the bloodstream secondary to the described gastrointestinal toxicity and was previously discovered on rectal swab (Fig. 1b) and fecal culture (day − 51).
Due to sustained neutropenia, BM aplasia and the availability of a suitable apheresis product, the CAR T-cell Taskforce proceeded with a stem cell boost of previously collected autologous CD34+ cells (3,1 × 106 cells) on day 46. The combination of a sudden rise in serum inflammatory markers and a strongly positive serum galactomannan (GM) assay on day 49 prompted diagnostic bronchoscopy, which revealed a diffuse infiltrate of alveolar and peri-bronchial tissue by Aspergillus fumigatus, consistent with fulminant invasive fungal pneumonia. Over the next week, the patient became increasingly hemodynamically unstable with poor peripheral oxygenation. Repeat bronchoscopy with bronchial lavage was positive for A. fumigatus and C. glabrata. After 50 days of G-CSF refractory aplasia, the autologous stem cells slowly engrafted leading to neutrophil recovery. However, this likely exacerbated the local inflammatory reaction in the lung, contributing to rapid deterioration of his respiratory status. Despite extensive supportive measures, the patient died on day 58 after CAR T-cell transfusion. Cause of death was confirmed by autopsy as invasive fungal pneumonia with multi-organ septic spread. Post-mortem examination revealed Candida spores in intestinal, colonic and rectal tissue. Of note, histopathologic BM analysis revealed signs of burgeoning hematopoietic regeneration (Fig. 1e).
Discussion and conclusions
Recent studies have shed light on the high incidence of prolonged and profound neutropenia after adoptive immunotherapy with CD19-specific CAR T-cells [1–3]. Clinical sequalae include severe infectious complications, which have emerged as the number one cause of long-term non-relapse mortality after CAR T-cell therapy [14]. In a seminal study, Hill and colleagues demonstrate that infectious complications are common with a cumulative incidence of 23% in the first 28 days after CAR T-cell transfusion and 14% between days 29–90. While bacterial infections were most common in the first month, viral infections – especially respiratory viruses – predominated after day 29, likely as a result of an impaired adaptive immune response due to B-cell aplasia [15]. Overall, most infections were mild to moderate and fatal infections were rare. Invasive mold infections were uncommon, ranging from 1 to 7% in CAR T-cell recipients [15–17]. In multivariate analyses, the use of systemic corticosteroids for the management of CRS or ICANS has emerged as a major risk factor of infection [18]. Certain inflammatory signatures – such as the “double peaks of IL-6” pattern observed in our patient – have been shown to confer an especially high risk of life-threatening infection [19].
This case highlights the combination of factors that precipitate a high risk of infectious complications in a CAR T-cell patient. First, the heavily pre-treated patient displayed B-cell aplasia and a diminished hematopoietic reserve (e.g. trilineage cytopenia) prior to lymphodepletion. Second, the patient developed classic complications of CAR T-cell therapy such as CRS and severe and prolonged ICANS, reflecting a pro-inflammatory state that represents an important risk factor for developing infections in CAR T-cell patients [16]. The subsequent application of high-dose corticosteroids impaired both innate and adaptive immunity [20]. Third, pancytopenia was profound, prolonged and not able to be reverted by growth factor support. Fourth, the patient had a history of infectious complications, including a course of fungal pneumonia 6 weeks prior to lymphodepletion, likely flaring up in the setting of the above three factors.
Our patient developed severe septic shock secondary to neutropenic colitis on day 24, highlighting the risk of a watch-and-wait approach to prolonged neutropenia after CAR T-cell therapy. A two-pronged approach to management appears prescient. On the one hand, measures to propagate hematopoietic recovery should be exhausted (causal therapy). This can range from G-CSF stimulation, to a trial of pulse-dose corticosteroids or anti-cytokine therapy (e.g. Anakinra, Tocilizumab), to a stem cell boost as a last resort in lymphoma patients who have undergone prior autologous stem cell transplantation. On the other hand, clinicians should be at high alert for infectious complications and adapt their infection surveillance and anti-infective prophylactic strategies accordingly. For example, therapeutic drug monitoring of posaconazole and meropenem levels may have revealed subtherapeutic dosing of these anti-infective agents in this patient [21]. The role of antifungal prophylaxis in the CAR T-cell patient remains inconclusive. Adequately powered studies addressing the duration of neutropenia after CAR T-cell therapy, and potential clinical determinants of invasive fungal infections, will be critical to gauge the benefit of antifungal prophylaxis in this patient collective.
Candida species are a leading cause of fungus-associated morbidity and mortality in severely immunocompromised patients [21]. On day 41, this patient developed breakthrough C. glabrata Candidemia on micafungin, in the setting of both underlying colonization and neutropenic colitis. A recent report implicated the gastrointestinal tract as major source of echinocandin drug resistance in a murine model of C. glabrata colonization and systemic dissemination [22]. Of note, breakthrough Candida infections on micafungin may occur at the employed dose level (50 mg/day IV), suggesting that this dose may have been inadequate to prevent subsequent Candidemia [23]. Though cases of C. glabrata colitis are extremely rare [24], an opportunistic infection could not be ruled out given that C. glabrata infiltrates were discovered in enteral and colonic mucosal tissue on post-mortem examination. Importantly, the patients’ clinical status deteriorated only after the stem cell boost resulted in signs of hematopoietic recovery. The paradoxical worsening of the pulmonary A. fumigatus infection is consistent with immune reconstitution inflammatory syndrome (IRIS), which has been previously described for HIV/AIDS [25] and for severely neutropenic patients with IPA [26]. In conclusion, this case emphasizes that infectious complications secondary to prolonged cytopenia influence non-relapse mortality after CAR T-cell therapy.
Abbreviations
ALCAbsolute Lymphocyte Count
ANCAbsolute Neutrophil Count
BMBone Marrow
CARChimeric antigen receptor
CBCComplete Blood Count
CRSCytokine release syndrome
CTCAECommon Terminology Criteria for Adverse Events
DLBCLDiffuse large B-cell lymphoma
FFPFresh frozen plasma
FLAIRFluid-attenuated inversion recovery
Flu/CyFludarabine/Cyclophosphamide
G-CSFGranulocyte colony stimulating factor
GIGastrointestinal
GMGalactomannan
HSPCsHematopoietic stem and progenitor cells
ICANSImmune effector cell-associated neurotoxicity syndrome
ICE-scoreImmune Effector Cell-associated Encephalopathy score
ICUIntensive care unit
IPAInvasive pulmonary aspergillosis
LDHLactate Dehydrogenase
LYRICLymphoma response to immunomodulatory therapy criteria
MDRDModification of Diet in Renal Disease
MPOMyeloperoxidase
PASPeriodic acid-Schiff
PBSCPeripheral Blood Stem Cell
VREVancomycin-resistant Enterococcus
WBCWhite Blood Count
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Acknowledgements
Not applicable.
Authors’ contributions
The original manuscript was written by KR. KR and WGK prepared the figures. MR performed the histological examination of the bone marrow. MS reviewed and edited the manuscript. The other authors (VB1, VB2, CS, PK, FS, KD, LvB, JS, OW, MD, MvBB) contributed to patient management and participated in drafting and editing the manuscript. All authors read and approved the final manuscript.
Funding
Not applicable. Open Access funding enabled and organized by Projekt DEAL.
Availability of data and materials
The authors did not use any database, software, or tools for the writing of this manuscript.
Ethics approval and consent to participate
The authors obtained consent from the deceased patient’s next-of-kin to participate.
Consent for publication
Written informed consent was obtained from the patient’s next-of-kin for publication of this Case report and any accompanying images. A copy of the written consent is available for review by the Editor of this journal.
Competing interests
The authors declare that they have no competing interests related with this case report. | CYCLOPHOSPHAMIDE, DOXORUBICIN HYDROCHLORIDE, METHYLPREDNISOLONE, PREDNISOLONE, RITUXIMAB, VINCRISTINE | DrugsGivenReaction | CC BY | 33509115 | 18,947,434 | 2021-01-28 |
Give an alphabetized list of all active substances of drugs taken by the patient who experienced 'Haemodynamic instability'. | Severe Candida glabrata pancolitis and fatal Aspergillus fumigatus pulmonary infection in the setting of bone marrow aplasia after CD19-directed CAR T-cell therapy - a case report.
BACKGROUND
Prolonged myelosuppression following CD19-directed CAR T-cell transfusion represents an important, yet underreported, adverse event. The resulting neutropenia and multifactorial immunosuppression can facilitate severe infectious complications.
METHODS
We describe the clinical course of a 59-year-old patient with relapsed/refractory DLBCL who received Axicabtagene-Ciloleucel (Axi-cel). The patient developed ASTCT grade I CRS and grade IV ICANS, necessitating admission to the neurological ICU and prolonged application of high-dose corticosteroids and other immunosuppressive agents. Importantly, neutropenia was profound (ANC < 100/μl), G-CSF-refractory, and prolonged, lasting more than 50 days. The patient developed severe septic shock 3 weeks after CAR transfusion while receiving anti-fungal prophylaxis with micafungin. His clinical status stabilized with broad anti-infective treatment and intensive supportive measures. An autologous stem cell backup was employed on day 46 to support hematopoietic recovery. Although the counts of the patient eventually started to recover, he developed an invasive pulmonary aspergillosis, which ultimately lead to respiratory failure and death. Postmortem examination revealed signs of Candida glabrata pancolitis.
CONCLUSIONS
This case highlights the increased risk for fatal infectious complications in patients who present with profound and prolonged cytopenia after CAR T-cell therapy. We describe a rare case of C. glabrata pancolitis associated with multifactorial immunosuppression. Although our patient succumbed to a fatal fungal infection, autologous stem cell boost was able to spur hematopoiesis and may represent an important therapeutic strategy for DLBCL patients with CAR T-cell associated bone marrow aplasia who have underwent prior stem cell harvest.
Background
When CD19-directed Chimeric Antigen Receptor (CAR) T-cell therapies were first introduced into the clinical setting, a set of distinctive side effects were observed, including Cytokine Release Syndrome (CRS) and immune effector cell-associated neurotoxicity syndrome (ICANS). As these treatments transition from large clinical trials to real-world implementation, new nuances of the side effect spectrum have emerged. This includes the observation that patients can present not only with grade 3–4 cytopenia (CTCAE v5.0), but also a syndrome of persistent cytopenia after CAR T-cell transfusion [1, 2]. Hematologic toxicity is common with one study demonstrating that neutropenia, thrombocytopenia and anemia occur in 94, 80 and 51% of patients respectively [3]. Risk factors for hematotoxicity include CRS grade, baseline cytopenia, and prior allogeneic stem cell transplantation within the last year [2, 3]. The fact that baseline hematopoietic reserve contributes to cytopenia in CAR T-cell patients may explain the variability in the incidence of hematoxicity in the real-world setting compared to the large registration trials, which set stringent hematologic exclusion criteria [4, 5]. The clinical utility of therapeutic rescue strategies that mitigate the risk of infectious complications secondary to long-term bone marrow (BM) aplasia, such as early autologous stem cell boost or Eltrombopag, remains unknown. Moreover, the relative paucity of reports concerning severe and life-threatening infections in the reported CD19-directed CAR T-cell trials necessitates the presentation of distinctive clinical courses that underline the risks of persistent cytopenia after CAR T-cell therapy in a real-world setting.
Case presentation
The 59-year-old male patient was initially diagnosed with stage IIIA follicular lymphoma in January 2018, which transformed to germinal center B-cell like DLBCL in October of the same year. Refractory to multiple cycles of Rituximab-based immunochemotherapy (Fig. 1a), the patient underwent leukapheresis for CAR T-cell therapy in April 2019. The patient experienced significant lymphoma progression during the manufacturing process of Axicabtagene ciloleucel (Axi-cel), manifesting itself in the form of malignant pleural effusions and progressive lymphadenopathy (Fig. 2a,c,e). In the six-week period between leukapheresis and lymphodepletion, the patient remained severely neutropenic after R-CHOP and developed possible invasive fungal disease (IFD) [6] (Fig. 3e) as well as E. coli septicemia secondary to a urinary tract infection. These infections were treated successfully with liposomal amphotericin B and piperacillin/tazobactam. Prior to lymphodepletion (D-5), the patient presented with an ECOG performance status of 1, intact renal and liver function, while observing residually depressed blood counts (WBC 1270/μl, ANC 700/μl, ALC 390/μl, Hemoglobin 7.2 g/dl, Platelets 20 G/l). BM histopathology showed a hypocellular marrow with no evidence of lymphoma infiltration. Analysis of lymphocyte subpopulations demonstrated severe B-cell aplasia and decreased absolute CD4+ (84/μl) and CD8+ (271/μl) counts. His anti-infective prophylaxis consisted of a combination of acyclovir, sulfamethoxazole/trimethoprim (TMP/SMZ), and posaconazole. The fludarabine/cyclophosphamide lympho-preparative regimen was applied on days − 5 to − 3 according to the provider’s protocol, followed by CAR T-cell transfusion on day 0.
Fig. 1 Overview of CAR T-cell mediated hematotoxicity and infectious complications. a Treatment course prior to CAR T-cell therapy. b Timeline of infectious complications during CAR T-cell treatment course. Positive microbiologic culture results are underlined. Bottom: Overview of utilized anti-infectives with the respective bars displaying the length of treatment. P/T = piperacillin/tazobactam, Ami = amikacin, Mero = meropenem, Vanco = vancomycin, Line = linezolid, Posa = posaconazole (p.o.), Mica = micafungin (i.v.), Amb = liposomal amphotericin B. The patient also received prophylactic acyclovir and sulfamethoxazole/trimethoprim (TMP/SMZ) during treatment. c Complete Blood Count (CBC) timeline. ANC (blue), platelet count (green), Hemoglobin (red). Transfusion events (green: platelet transfusion, red: pRBC transfusion) and G-CSF support (blue bar) are integrated in the curve. d Dynamics of Serum Inflammatory Markers. Infectious complications are superimposed above the graph. e Histopathologic analysis of BM biopsies demonstrating severe BM aplasia 1 month after CAR T-cell transfusion (Day 32, upper panel) and evidence of recovering hematopoiesis following autologous stem cell transfer (Autopsy, lower panel). Immunohistochemical staining for myeloperoxidase (= MPO) highlighting strong activation of myelopoiesis (right panel)
Fig. 2 Radiographic evidence of partial response to Axi-cel after 36 days. Contrast-enhanced CT abdomen (axial view) displaying pleural manifestations before (a) and after (b) CAR T-cell treatment. Involved paraaortic lymph nodes (red arrows) demonstrate an interval decrease in size (c-d, e-f). The inset of panel F depicts splenic hypodensities consistent with necrosis of tumor tissue secondary to immune therapy and a reduction of splenomegaly. G Graphical depiction of response over time. Tumor extent was quantified as the sum of the product of perpendicular diameters according to Lugano criteria over 3 time points and is graphed on the y-axis. H Timeline of LDH levels (U/l). The increase in LDH levels at day 25 correlated with the gastrointestinal toxicity and liver dysfunction
Fig. 3 Multi-organ toxicity secondary to CD19-directed CAR T-cell therapy. a Contrast-enhanced CT abdomen demonstrating a non-inflamed baseline state of GI mucosal tissue prior to CAR T therapy. b Panmural swelling of the sigma (left panel), ascending colon (middle panel), and stomach. c Non-pathologic CT of the brain. d Axial FLAIR-weighted (left), T1-weighted contrast-enhanced (middle), and diffusion-weighted (right) MRI displaying no evidence of cerebral edema, white matter lesions, diffusion restriction, microbleeds, meningeal enhancement or contrast enhancing lesions. e High-resolution CT thorax with bilateral fungal infiltrates observing the typical halo configuration 6 weeks prior to CAR T-cell transfusion. f On day − 3 the right-sided infiltrates have decreased in size. The left lung is collapsed due to malignant pleural effusion. g Lung parenchyma exhibiting an infiltration of non-dimorphic blastoconidial morphology consistent with Candida glabrata. h PAS staining of a lung specimen highlights septated hiphae and acute-angle branching, features consistent of with aspergillus infection
During lymphodepletion the patient developed an upper respiratory infection, presenting with a non-productive cough and a sputum culture positive for Bordetella bronchiseptica, which resolved clinically after antibiotic treatment with piperacillin/tazobactam. On day 7, the patient developed fever with a stable cardiopulmonary function and concomitant IL-6 rise (Fig. 1d), which was classified as CRS grade I according to ASTCT consensus grading [7] in the absence of positive blood cultures and other foci. Due to persistent fever refractory to antipyretic treatment, four total doses of tocilizumab (8 mg/kg) were applied over 36 h. Starting on day 9, the patient deteriorated neurologically with a depressed state of consciousness prompting the diagnosis of grade IV ICANS. The patient was transferred to the neurological ICU, and high-dose corticosteroids (methylprednisolone 1000 mg daily) were initiated. CSF-analysis displayed subtle pleocytosis, but revealed no signs of CNS infection (viral, bacterial and fungal) or meningeal involvement of the DLBCL. CT and MR imaging of the brain exhibited none of the pathological findings reported for ICANS [8] or CNS infection [9](Fig. 3c-d). After 5 days of high-dose methylprednisolone, the patient’s neurological status slowly improved, and corticosteroids could be tapered.
Partial response to Axicabtagene-Ciloleucel after 36 days according to Lugano criteria
While the patient’s initial clinical course was fraught with complications, CT staging performed at day 36 demonstrated a partial response to CAR T-cell therapy according to Lugano and Lyric criteria (Fig. 2a-g). This was particularly evident for the pleural manifestations of the underlying DLBCL, which was accompanied by an interval decrease in pleural effusions and subjective dyspnea (Fig. 2a-b). Multiple nodal sites including paraaortic (Fig. 2c-d) and parailiac lymph nodes (Fig. 2e-f) exhibited significant regression of tumor size (Fig. 2g). Moreover, the patient displayed splenic hypodensities consistent with either tumor tissue necrosis or infection-associated inflammatory changes (inset, Fig. 2f). These CT-morphologic findings were accompanied by a decrease of LDH levels (Fig. 2h).
Prolonged cytopenia lead to the development of severe neutropenic colitis and fatal fungal pneumonia
The patient presented with significant myelotoxicity and sustained transfusion dependency after CAR T-cell administration (Fig. 1c). The overall duration of profound neutropenia – defined as an ANC < 100/μl [10] – was 52 days. Because of the severity of ICANS, the clinicians chose to hold G-CSF during this time period due to concerns for risk of worsening toxicity [11].
While receiving broad anti-infectives (acyclovir, TMP/SMZ, posaconazole, meropenem), the patient developed breakthrough septic shock on day 24. He exhibited fever (39.5 °C), hypotension (70/30 mmHg), tachycardia (160/min), as well as lactic acidosis (lactate: 10.7 mmol/l). The patient was non-conversant, non-oriented, and was not able to localize symptoms. However, he had described epigastric tenderness and subtle changes in stool consistency and frequency on the previous day. As a result, abdominal CT imaging was obtained, which displayed severe pancolitis, as evidenced by pronounced mucosal thickening with edematous changes ranging from the ascending colon to the rectum (Fig. 3a-b). Labs were notable for an acute spike of serum inflammatory parameters (Il-6 > 500.000 pg/ml, CRP 5.7 mg/dl, Procalcitonin 11.2 ng/ml, Fig. 1d). Following ICU transfer, high-dose vasopressor support with norepinephrine was initiated together with volume resuscitation to maintain organ perfusion. Due to progressive loss of consciousness the patient was intubated and mechanically ventilated. To control the proinflammatory state, extracorporeal cytokine absorption (Cytosorb®) was performed, which resulted in a decrease of soluble inflammatory markers in the subsequent days. Arterial blood cultures were positive for vancomycin-resistant enterococci (VRE), and the antibiotic treatment was escalated to include linezolid along with meropenem (Fig. 1b). The ICU team transitioned antifungal prophylaxis from posaconazole to an echinocandine (micafungin 50 mg IV) due to ECG changes and concerns for drug interactions on day 24. Though he remained in critical condition, in the coming weeks his clinical condition stabilized and both the catecholamine rate and volume support could be reduced. To determine the origin of sustained myelosuppression, a bone marrow biopsy was obtained, which depicted a hypocellular marrow and severe aplasia affecting all hematopoietic lineages (Fig. 1e). On days 41 and 49, surveillance blood cultures were positive for Candida glabrata, a commensal fungal organism of human mucosal tissues [12] harboring an intrinsic azole resistance [13]. Susceptibility testing confirmed the azole-resistance of C. glabrata isolates. The antimycotic therapy was escalated from micafungin to liposomal amphotericin B. C. glabrata likely disseminated to the bloodstream secondary to the described gastrointestinal toxicity and was previously discovered on rectal swab (Fig. 1b) and fecal culture (day − 51).
Due to sustained neutropenia, BM aplasia and the availability of a suitable apheresis product, the CAR T-cell Taskforce proceeded with a stem cell boost of previously collected autologous CD34+ cells (3,1 × 106 cells) on day 46. The combination of a sudden rise in serum inflammatory markers and a strongly positive serum galactomannan (GM) assay on day 49 prompted diagnostic bronchoscopy, which revealed a diffuse infiltrate of alveolar and peri-bronchial tissue by Aspergillus fumigatus, consistent with fulminant invasive fungal pneumonia. Over the next week, the patient became increasingly hemodynamically unstable with poor peripheral oxygenation. Repeat bronchoscopy with bronchial lavage was positive for A. fumigatus and C. glabrata. After 50 days of G-CSF refractory aplasia, the autologous stem cells slowly engrafted leading to neutrophil recovery. However, this likely exacerbated the local inflammatory reaction in the lung, contributing to rapid deterioration of his respiratory status. Despite extensive supportive measures, the patient died on day 58 after CAR T-cell transfusion. Cause of death was confirmed by autopsy as invasive fungal pneumonia with multi-organ septic spread. Post-mortem examination revealed Candida spores in intestinal, colonic and rectal tissue. Of note, histopathologic BM analysis revealed signs of burgeoning hematopoietic regeneration (Fig. 1e).
Discussion and conclusions
Recent studies have shed light on the high incidence of prolonged and profound neutropenia after adoptive immunotherapy with CD19-specific CAR T-cells [1–3]. Clinical sequalae include severe infectious complications, which have emerged as the number one cause of long-term non-relapse mortality after CAR T-cell therapy [14]. In a seminal study, Hill and colleagues demonstrate that infectious complications are common with a cumulative incidence of 23% in the first 28 days after CAR T-cell transfusion and 14% between days 29–90. While bacterial infections were most common in the first month, viral infections – especially respiratory viruses – predominated after day 29, likely as a result of an impaired adaptive immune response due to B-cell aplasia [15]. Overall, most infections were mild to moderate and fatal infections were rare. Invasive mold infections were uncommon, ranging from 1 to 7% in CAR T-cell recipients [15–17]. In multivariate analyses, the use of systemic corticosteroids for the management of CRS or ICANS has emerged as a major risk factor of infection [18]. Certain inflammatory signatures – such as the “double peaks of IL-6” pattern observed in our patient – have been shown to confer an especially high risk of life-threatening infection [19].
This case highlights the combination of factors that precipitate a high risk of infectious complications in a CAR T-cell patient. First, the heavily pre-treated patient displayed B-cell aplasia and a diminished hematopoietic reserve (e.g. trilineage cytopenia) prior to lymphodepletion. Second, the patient developed classic complications of CAR T-cell therapy such as CRS and severe and prolonged ICANS, reflecting a pro-inflammatory state that represents an important risk factor for developing infections in CAR T-cell patients [16]. The subsequent application of high-dose corticosteroids impaired both innate and adaptive immunity [20]. Third, pancytopenia was profound, prolonged and not able to be reverted by growth factor support. Fourth, the patient had a history of infectious complications, including a course of fungal pneumonia 6 weeks prior to lymphodepletion, likely flaring up in the setting of the above three factors.
Our patient developed severe septic shock secondary to neutropenic colitis on day 24, highlighting the risk of a watch-and-wait approach to prolonged neutropenia after CAR T-cell therapy. A two-pronged approach to management appears prescient. On the one hand, measures to propagate hematopoietic recovery should be exhausted (causal therapy). This can range from G-CSF stimulation, to a trial of pulse-dose corticosteroids or anti-cytokine therapy (e.g. Anakinra, Tocilizumab), to a stem cell boost as a last resort in lymphoma patients who have undergone prior autologous stem cell transplantation. On the other hand, clinicians should be at high alert for infectious complications and adapt their infection surveillance and anti-infective prophylactic strategies accordingly. For example, therapeutic drug monitoring of posaconazole and meropenem levels may have revealed subtherapeutic dosing of these anti-infective agents in this patient [21]. The role of antifungal prophylaxis in the CAR T-cell patient remains inconclusive. Adequately powered studies addressing the duration of neutropenia after CAR T-cell therapy, and potential clinical determinants of invasive fungal infections, will be critical to gauge the benefit of antifungal prophylaxis in this patient collective.
Candida species are a leading cause of fungus-associated morbidity and mortality in severely immunocompromised patients [21]. On day 41, this patient developed breakthrough C. glabrata Candidemia on micafungin, in the setting of both underlying colonization and neutropenic colitis. A recent report implicated the gastrointestinal tract as major source of echinocandin drug resistance in a murine model of C. glabrata colonization and systemic dissemination [22]. Of note, breakthrough Candida infections on micafungin may occur at the employed dose level (50 mg/day IV), suggesting that this dose may have been inadequate to prevent subsequent Candidemia [23]. Though cases of C. glabrata colitis are extremely rare [24], an opportunistic infection could not be ruled out given that C. glabrata infiltrates were discovered in enteral and colonic mucosal tissue on post-mortem examination. Importantly, the patients’ clinical status deteriorated only after the stem cell boost resulted in signs of hematopoietic recovery. The paradoxical worsening of the pulmonary A. fumigatus infection is consistent with immune reconstitution inflammatory syndrome (IRIS), which has been previously described for HIV/AIDS [25] and for severely neutropenic patients with IPA [26]. In conclusion, this case emphasizes that infectious complications secondary to prolonged cytopenia influence non-relapse mortality after CAR T-cell therapy.
Abbreviations
ALCAbsolute Lymphocyte Count
ANCAbsolute Neutrophil Count
BMBone Marrow
CARChimeric antigen receptor
CBCComplete Blood Count
CRSCytokine release syndrome
CTCAECommon Terminology Criteria for Adverse Events
DLBCLDiffuse large B-cell lymphoma
FFPFresh frozen plasma
FLAIRFluid-attenuated inversion recovery
Flu/CyFludarabine/Cyclophosphamide
G-CSFGranulocyte colony stimulating factor
GIGastrointestinal
GMGalactomannan
HSPCsHematopoietic stem and progenitor cells
ICANSImmune effector cell-associated neurotoxicity syndrome
ICE-scoreImmune Effector Cell-associated Encephalopathy score
ICUIntensive care unit
IPAInvasive pulmonary aspergillosis
LDHLactate Dehydrogenase
LYRICLymphoma response to immunomodulatory therapy criteria
MDRDModification of Diet in Renal Disease
MPOMyeloperoxidase
PASPeriodic acid-Schiff
PBSCPeripheral Blood Stem Cell
VREVancomycin-resistant Enterococcus
WBCWhite Blood Count
Publisher’s Note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
Acknowledgements
Not applicable.
Authors’ contributions
The original manuscript was written by KR. KR and WGK prepared the figures. MR performed the histological examination of the bone marrow. MS reviewed and edited the manuscript. The other authors (VB1, VB2, CS, PK, FS, KD, LvB, JS, OW, MD, MvBB) contributed to patient management and participated in drafting and editing the manuscript. All authors read and approved the final manuscript.
Funding
Not applicable. Open Access funding enabled and organized by Projekt DEAL.
Availability of data and materials
The authors did not use any database, software, or tools for the writing of this manuscript.
Ethics approval and consent to participate
The authors obtained consent from the deceased patient’s next-of-kin to participate.
Consent for publication
Written informed consent was obtained from the patient’s next-of-kin for publication of this Case report and any accompanying images. A copy of the written consent is available for review by the Editor of this journal.
Competing interests
The authors declare that they have no competing interests related with this case report. | CYCLOPHOSPHAMIDE, DOXORUBICIN HYDROCHLORIDE, METHYLPREDNISOLONE, PREDNISOLONE, RITUXIMAB, VINCRISTINE | DrugsGivenReaction | CC BY | 33509115 | 18,947,434 | 2021-01-28 |
Give an alphabetized list of all active substances of drugs taken by the patient who experienced 'Lactic acidosis'. | Severe Candida glabrata pancolitis and fatal Aspergillus fumigatus pulmonary infection in the setting of bone marrow aplasia after CD19-directed CAR T-cell therapy - a case report.
BACKGROUND
Prolonged myelosuppression following CD19-directed CAR T-cell transfusion represents an important, yet underreported, adverse event. The resulting neutropenia and multifactorial immunosuppression can facilitate severe infectious complications.
METHODS
We describe the clinical course of a 59-year-old patient with relapsed/refractory DLBCL who received Axicabtagene-Ciloleucel (Axi-cel). The patient developed ASTCT grade I CRS and grade IV ICANS, necessitating admission to the neurological ICU and prolonged application of high-dose corticosteroids and other immunosuppressive agents. Importantly, neutropenia was profound (ANC < 100/μl), G-CSF-refractory, and prolonged, lasting more than 50 days. The patient developed severe septic shock 3 weeks after CAR transfusion while receiving anti-fungal prophylaxis with micafungin. His clinical status stabilized with broad anti-infective treatment and intensive supportive measures. An autologous stem cell backup was employed on day 46 to support hematopoietic recovery. Although the counts of the patient eventually started to recover, he developed an invasive pulmonary aspergillosis, which ultimately lead to respiratory failure and death. Postmortem examination revealed signs of Candida glabrata pancolitis.
CONCLUSIONS
This case highlights the increased risk for fatal infectious complications in patients who present with profound and prolonged cytopenia after CAR T-cell therapy. We describe a rare case of C. glabrata pancolitis associated with multifactorial immunosuppression. Although our patient succumbed to a fatal fungal infection, autologous stem cell boost was able to spur hematopoiesis and may represent an important therapeutic strategy for DLBCL patients with CAR T-cell associated bone marrow aplasia who have underwent prior stem cell harvest.
Background
When CD19-directed Chimeric Antigen Receptor (CAR) T-cell therapies were first introduced into the clinical setting, a set of distinctive side effects were observed, including Cytokine Release Syndrome (CRS) and immune effector cell-associated neurotoxicity syndrome (ICANS). As these treatments transition from large clinical trials to real-world implementation, new nuances of the side effect spectrum have emerged. This includes the observation that patients can present not only with grade 3–4 cytopenia (CTCAE v5.0), but also a syndrome of persistent cytopenia after CAR T-cell transfusion [1, 2]. Hematologic toxicity is common with one study demonstrating that neutropenia, thrombocytopenia and anemia occur in 94, 80 and 51% of patients respectively [3]. Risk factors for hematotoxicity include CRS grade, baseline cytopenia, and prior allogeneic stem cell transplantation within the last year [2, 3]. The fact that baseline hematopoietic reserve contributes to cytopenia in CAR T-cell patients may explain the variability in the incidence of hematoxicity in the real-world setting compared to the large registration trials, which set stringent hematologic exclusion criteria [4, 5]. The clinical utility of therapeutic rescue strategies that mitigate the risk of infectious complications secondary to long-term bone marrow (BM) aplasia, such as early autologous stem cell boost or Eltrombopag, remains unknown. Moreover, the relative paucity of reports concerning severe and life-threatening infections in the reported CD19-directed CAR T-cell trials necessitates the presentation of distinctive clinical courses that underline the risks of persistent cytopenia after CAR T-cell therapy in a real-world setting.
Case presentation
The 59-year-old male patient was initially diagnosed with stage IIIA follicular lymphoma in January 2018, which transformed to germinal center B-cell like DLBCL in October of the same year. Refractory to multiple cycles of Rituximab-based immunochemotherapy (Fig. 1a), the patient underwent leukapheresis for CAR T-cell therapy in April 2019. The patient experienced significant lymphoma progression during the manufacturing process of Axicabtagene ciloleucel (Axi-cel), manifesting itself in the form of malignant pleural effusions and progressive lymphadenopathy (Fig. 2a,c,e). In the six-week period between leukapheresis and lymphodepletion, the patient remained severely neutropenic after R-CHOP and developed possible invasive fungal disease (IFD) [6] (Fig. 3e) as well as E. coli septicemia secondary to a urinary tract infection. These infections were treated successfully with liposomal amphotericin B and piperacillin/tazobactam. Prior to lymphodepletion (D-5), the patient presented with an ECOG performance status of 1, intact renal and liver function, while observing residually depressed blood counts (WBC 1270/μl, ANC 700/μl, ALC 390/μl, Hemoglobin 7.2 g/dl, Platelets 20 G/l). BM histopathology showed a hypocellular marrow with no evidence of lymphoma infiltration. Analysis of lymphocyte subpopulations demonstrated severe B-cell aplasia and decreased absolute CD4+ (84/μl) and CD8+ (271/μl) counts. His anti-infective prophylaxis consisted of a combination of acyclovir, sulfamethoxazole/trimethoprim (TMP/SMZ), and posaconazole. The fludarabine/cyclophosphamide lympho-preparative regimen was applied on days − 5 to − 3 according to the provider’s protocol, followed by CAR T-cell transfusion on day 0.
Fig. 1 Overview of CAR T-cell mediated hematotoxicity and infectious complications. a Treatment course prior to CAR T-cell therapy. b Timeline of infectious complications during CAR T-cell treatment course. Positive microbiologic culture results are underlined. Bottom: Overview of utilized anti-infectives with the respective bars displaying the length of treatment. P/T = piperacillin/tazobactam, Ami = amikacin, Mero = meropenem, Vanco = vancomycin, Line = linezolid, Posa = posaconazole (p.o.), Mica = micafungin (i.v.), Amb = liposomal amphotericin B. The patient also received prophylactic acyclovir and sulfamethoxazole/trimethoprim (TMP/SMZ) during treatment. c Complete Blood Count (CBC) timeline. ANC (blue), platelet count (green), Hemoglobin (red). Transfusion events (green: platelet transfusion, red: pRBC transfusion) and G-CSF support (blue bar) are integrated in the curve. d Dynamics of Serum Inflammatory Markers. Infectious complications are superimposed above the graph. e Histopathologic analysis of BM biopsies demonstrating severe BM aplasia 1 month after CAR T-cell transfusion (Day 32, upper panel) and evidence of recovering hematopoiesis following autologous stem cell transfer (Autopsy, lower panel). Immunohistochemical staining for myeloperoxidase (= MPO) highlighting strong activation of myelopoiesis (right panel)
Fig. 2 Radiographic evidence of partial response to Axi-cel after 36 days. Contrast-enhanced CT abdomen (axial view) displaying pleural manifestations before (a) and after (b) CAR T-cell treatment. Involved paraaortic lymph nodes (red arrows) demonstrate an interval decrease in size (c-d, e-f). The inset of panel F depicts splenic hypodensities consistent with necrosis of tumor tissue secondary to immune therapy and a reduction of splenomegaly. G Graphical depiction of response over time. Tumor extent was quantified as the sum of the product of perpendicular diameters according to Lugano criteria over 3 time points and is graphed on the y-axis. H Timeline of LDH levels (U/l). The increase in LDH levels at day 25 correlated with the gastrointestinal toxicity and liver dysfunction
Fig. 3 Multi-organ toxicity secondary to CD19-directed CAR T-cell therapy. a Contrast-enhanced CT abdomen demonstrating a non-inflamed baseline state of GI mucosal tissue prior to CAR T therapy. b Panmural swelling of the sigma (left panel), ascending colon (middle panel), and stomach. c Non-pathologic CT of the brain. d Axial FLAIR-weighted (left), T1-weighted contrast-enhanced (middle), and diffusion-weighted (right) MRI displaying no evidence of cerebral edema, white matter lesions, diffusion restriction, microbleeds, meningeal enhancement or contrast enhancing lesions. e High-resolution CT thorax with bilateral fungal infiltrates observing the typical halo configuration 6 weeks prior to CAR T-cell transfusion. f On day − 3 the right-sided infiltrates have decreased in size. The left lung is collapsed due to malignant pleural effusion. g Lung parenchyma exhibiting an infiltration of non-dimorphic blastoconidial morphology consistent with Candida glabrata. h PAS staining of a lung specimen highlights septated hiphae and acute-angle branching, features consistent of with aspergillus infection
During lymphodepletion the patient developed an upper respiratory infection, presenting with a non-productive cough and a sputum culture positive for Bordetella bronchiseptica, which resolved clinically after antibiotic treatment with piperacillin/tazobactam. On day 7, the patient developed fever with a stable cardiopulmonary function and concomitant IL-6 rise (Fig. 1d), which was classified as CRS grade I according to ASTCT consensus grading [7] in the absence of positive blood cultures and other foci. Due to persistent fever refractory to antipyretic treatment, four total doses of tocilizumab (8 mg/kg) were applied over 36 h. Starting on day 9, the patient deteriorated neurologically with a depressed state of consciousness prompting the diagnosis of grade IV ICANS. The patient was transferred to the neurological ICU, and high-dose corticosteroids (methylprednisolone 1000 mg daily) were initiated. CSF-analysis displayed subtle pleocytosis, but revealed no signs of CNS infection (viral, bacterial and fungal) or meningeal involvement of the DLBCL. CT and MR imaging of the brain exhibited none of the pathological findings reported for ICANS [8] or CNS infection [9](Fig. 3c-d). After 5 days of high-dose methylprednisolone, the patient’s neurological status slowly improved, and corticosteroids could be tapered.
Partial response to Axicabtagene-Ciloleucel after 36 days according to Lugano criteria
While the patient’s initial clinical course was fraught with complications, CT staging performed at day 36 demonstrated a partial response to CAR T-cell therapy according to Lugano and Lyric criteria (Fig. 2a-g). This was particularly evident for the pleural manifestations of the underlying DLBCL, which was accompanied by an interval decrease in pleural effusions and subjective dyspnea (Fig. 2a-b). Multiple nodal sites including paraaortic (Fig. 2c-d) and parailiac lymph nodes (Fig. 2e-f) exhibited significant regression of tumor size (Fig. 2g). Moreover, the patient displayed splenic hypodensities consistent with either tumor tissue necrosis or infection-associated inflammatory changes (inset, Fig. 2f). These CT-morphologic findings were accompanied by a decrease of LDH levels (Fig. 2h).
Prolonged cytopenia lead to the development of severe neutropenic colitis and fatal fungal pneumonia
The patient presented with significant myelotoxicity and sustained transfusion dependency after CAR T-cell administration (Fig. 1c). The overall duration of profound neutropenia – defined as an ANC < 100/μl [10] – was 52 days. Because of the severity of ICANS, the clinicians chose to hold G-CSF during this time period due to concerns for risk of worsening toxicity [11].
While receiving broad anti-infectives (acyclovir, TMP/SMZ, posaconazole, meropenem), the patient developed breakthrough septic shock on day 24. He exhibited fever (39.5 °C), hypotension (70/30 mmHg), tachycardia (160/min), as well as lactic acidosis (lactate: 10.7 mmol/l). The patient was non-conversant, non-oriented, and was not able to localize symptoms. However, he had described epigastric tenderness and subtle changes in stool consistency and frequency on the previous day. As a result, abdominal CT imaging was obtained, which displayed severe pancolitis, as evidenced by pronounced mucosal thickening with edematous changes ranging from the ascending colon to the rectum (Fig. 3a-b). Labs were notable for an acute spike of serum inflammatory parameters (Il-6 > 500.000 pg/ml, CRP 5.7 mg/dl, Procalcitonin 11.2 ng/ml, Fig. 1d). Following ICU transfer, high-dose vasopressor support with norepinephrine was initiated together with volume resuscitation to maintain organ perfusion. Due to progressive loss of consciousness the patient was intubated and mechanically ventilated. To control the proinflammatory state, extracorporeal cytokine absorption (Cytosorb®) was performed, which resulted in a decrease of soluble inflammatory markers in the subsequent days. Arterial blood cultures were positive for vancomycin-resistant enterococci (VRE), and the antibiotic treatment was escalated to include linezolid along with meropenem (Fig. 1b). The ICU team transitioned antifungal prophylaxis from posaconazole to an echinocandine (micafungin 50 mg IV) due to ECG changes and concerns for drug interactions on day 24. Though he remained in critical condition, in the coming weeks his clinical condition stabilized and both the catecholamine rate and volume support could be reduced. To determine the origin of sustained myelosuppression, a bone marrow biopsy was obtained, which depicted a hypocellular marrow and severe aplasia affecting all hematopoietic lineages (Fig. 1e). On days 41 and 49, surveillance blood cultures were positive for Candida glabrata, a commensal fungal organism of human mucosal tissues [12] harboring an intrinsic azole resistance [13]. Susceptibility testing confirmed the azole-resistance of C. glabrata isolates. The antimycotic therapy was escalated from micafungin to liposomal amphotericin B. C. glabrata likely disseminated to the bloodstream secondary to the described gastrointestinal toxicity and was previously discovered on rectal swab (Fig. 1b) and fecal culture (day − 51).
Due to sustained neutropenia, BM aplasia and the availability of a suitable apheresis product, the CAR T-cell Taskforce proceeded with a stem cell boost of previously collected autologous CD34+ cells (3,1 × 106 cells) on day 46. The combination of a sudden rise in serum inflammatory markers and a strongly positive serum galactomannan (GM) assay on day 49 prompted diagnostic bronchoscopy, which revealed a diffuse infiltrate of alveolar and peri-bronchial tissue by Aspergillus fumigatus, consistent with fulminant invasive fungal pneumonia. Over the next week, the patient became increasingly hemodynamically unstable with poor peripheral oxygenation. Repeat bronchoscopy with bronchial lavage was positive for A. fumigatus and C. glabrata. After 50 days of G-CSF refractory aplasia, the autologous stem cells slowly engrafted leading to neutrophil recovery. However, this likely exacerbated the local inflammatory reaction in the lung, contributing to rapid deterioration of his respiratory status. Despite extensive supportive measures, the patient died on day 58 after CAR T-cell transfusion. Cause of death was confirmed by autopsy as invasive fungal pneumonia with multi-organ septic spread. Post-mortem examination revealed Candida spores in intestinal, colonic and rectal tissue. Of note, histopathologic BM analysis revealed signs of burgeoning hematopoietic regeneration (Fig. 1e).
Discussion and conclusions
Recent studies have shed light on the high incidence of prolonged and profound neutropenia after adoptive immunotherapy with CD19-specific CAR T-cells [1–3]. Clinical sequalae include severe infectious complications, which have emerged as the number one cause of long-term non-relapse mortality after CAR T-cell therapy [14]. In a seminal study, Hill and colleagues demonstrate that infectious complications are common with a cumulative incidence of 23% in the first 28 days after CAR T-cell transfusion and 14% between days 29–90. While bacterial infections were most common in the first month, viral infections – especially respiratory viruses – predominated after day 29, likely as a result of an impaired adaptive immune response due to B-cell aplasia [15]. Overall, most infections were mild to moderate and fatal infections were rare. Invasive mold infections were uncommon, ranging from 1 to 7% in CAR T-cell recipients [15–17]. In multivariate analyses, the use of systemic corticosteroids for the management of CRS or ICANS has emerged as a major risk factor of infection [18]. Certain inflammatory signatures – such as the “double peaks of IL-6” pattern observed in our patient – have been shown to confer an especially high risk of life-threatening infection [19].
This case highlights the combination of factors that precipitate a high risk of infectious complications in a CAR T-cell patient. First, the heavily pre-treated patient displayed B-cell aplasia and a diminished hematopoietic reserve (e.g. trilineage cytopenia) prior to lymphodepletion. Second, the patient developed classic complications of CAR T-cell therapy such as CRS and severe and prolonged ICANS, reflecting a pro-inflammatory state that represents an important risk factor for developing infections in CAR T-cell patients [16]. The subsequent application of high-dose corticosteroids impaired both innate and adaptive immunity [20]. Third, pancytopenia was profound, prolonged and not able to be reverted by growth factor support. Fourth, the patient had a history of infectious complications, including a course of fungal pneumonia 6 weeks prior to lymphodepletion, likely flaring up in the setting of the above three factors.
Our patient developed severe septic shock secondary to neutropenic colitis on day 24, highlighting the risk of a watch-and-wait approach to prolonged neutropenia after CAR T-cell therapy. A two-pronged approach to management appears prescient. On the one hand, measures to propagate hematopoietic recovery should be exhausted (causal therapy). This can range from G-CSF stimulation, to a trial of pulse-dose corticosteroids or anti-cytokine therapy (e.g. Anakinra, Tocilizumab), to a stem cell boost as a last resort in lymphoma patients who have undergone prior autologous stem cell transplantation. On the other hand, clinicians should be at high alert for infectious complications and adapt their infection surveillance and anti-infective prophylactic strategies accordingly. For example, therapeutic drug monitoring of posaconazole and meropenem levels may have revealed subtherapeutic dosing of these anti-infective agents in this patient [21]. The role of antifungal prophylaxis in the CAR T-cell patient remains inconclusive. Adequately powered studies addressing the duration of neutropenia after CAR T-cell therapy, and potential clinical determinants of invasive fungal infections, will be critical to gauge the benefit of antifungal prophylaxis in this patient collective.
Candida species are a leading cause of fungus-associated morbidity and mortality in severely immunocompromised patients [21]. On day 41, this patient developed breakthrough C. glabrata Candidemia on micafungin, in the setting of both underlying colonization and neutropenic colitis. A recent report implicated the gastrointestinal tract as major source of echinocandin drug resistance in a murine model of C. glabrata colonization and systemic dissemination [22]. Of note, breakthrough Candida infections on micafungin may occur at the employed dose level (50 mg/day IV), suggesting that this dose may have been inadequate to prevent subsequent Candidemia [23]. Though cases of C. glabrata colitis are extremely rare [24], an opportunistic infection could not be ruled out given that C. glabrata infiltrates were discovered in enteral and colonic mucosal tissue on post-mortem examination. Importantly, the patients’ clinical status deteriorated only after the stem cell boost resulted in signs of hematopoietic recovery. The paradoxical worsening of the pulmonary A. fumigatus infection is consistent with immune reconstitution inflammatory syndrome (IRIS), which has been previously described for HIV/AIDS [25] and for severely neutropenic patients with IPA [26]. In conclusion, this case emphasizes that infectious complications secondary to prolonged cytopenia influence non-relapse mortality after CAR T-cell therapy.
Abbreviations
ALCAbsolute Lymphocyte Count
ANCAbsolute Neutrophil Count
BMBone Marrow
CARChimeric antigen receptor
CBCComplete Blood Count
CRSCytokine release syndrome
CTCAECommon Terminology Criteria for Adverse Events
DLBCLDiffuse large B-cell lymphoma
FFPFresh frozen plasma
FLAIRFluid-attenuated inversion recovery
Flu/CyFludarabine/Cyclophosphamide
G-CSFGranulocyte colony stimulating factor
GIGastrointestinal
GMGalactomannan
HSPCsHematopoietic stem and progenitor cells
ICANSImmune effector cell-associated neurotoxicity syndrome
ICE-scoreImmune Effector Cell-associated Encephalopathy score
ICUIntensive care unit
IPAInvasive pulmonary aspergillosis
LDHLactate Dehydrogenase
LYRICLymphoma response to immunomodulatory therapy criteria
MDRDModification of Diet in Renal Disease
MPOMyeloperoxidase
PASPeriodic acid-Schiff
PBSCPeripheral Blood Stem Cell
VREVancomycin-resistant Enterococcus
WBCWhite Blood Count
Publisher’s Note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
Acknowledgements
Not applicable.
Authors’ contributions
The original manuscript was written by KR. KR and WGK prepared the figures. MR performed the histological examination of the bone marrow. MS reviewed and edited the manuscript. The other authors (VB1, VB2, CS, PK, FS, KD, LvB, JS, OW, MD, MvBB) contributed to patient management and participated in drafting and editing the manuscript. All authors read and approved the final manuscript.
Funding
Not applicable. Open Access funding enabled and organized by Projekt DEAL.
Availability of data and materials
The authors did not use any database, software, or tools for the writing of this manuscript.
Ethics approval and consent to participate
The authors obtained consent from the deceased patient’s next-of-kin to participate.
Consent for publication
Written informed consent was obtained from the patient’s next-of-kin for publication of this Case report and any accompanying images. A copy of the written consent is available for review by the Editor of this journal.
Competing interests
The authors declare that they have no competing interests related with this case report. | CYCLOPHOSPHAMIDE, DOXORUBICIN HYDROCHLORIDE, METHYLPREDNISOLONE, PREDNISOLONE, RITUXIMAB, VINCRISTINE | DrugsGivenReaction | CC BY | 33509115 | 18,947,434 | 2021-01-28 |
Give an alphabetized list of all active substances of drugs taken by the patient who experienced 'Loss of consciousness'. | Severe Candida glabrata pancolitis and fatal Aspergillus fumigatus pulmonary infection in the setting of bone marrow aplasia after CD19-directed CAR T-cell therapy - a case report.
BACKGROUND
Prolonged myelosuppression following CD19-directed CAR T-cell transfusion represents an important, yet underreported, adverse event. The resulting neutropenia and multifactorial immunosuppression can facilitate severe infectious complications.
METHODS
We describe the clinical course of a 59-year-old patient with relapsed/refractory DLBCL who received Axicabtagene-Ciloleucel (Axi-cel). The patient developed ASTCT grade I CRS and grade IV ICANS, necessitating admission to the neurological ICU and prolonged application of high-dose corticosteroids and other immunosuppressive agents. Importantly, neutropenia was profound (ANC < 100/μl), G-CSF-refractory, and prolonged, lasting more than 50 days. The patient developed severe septic shock 3 weeks after CAR transfusion while receiving anti-fungal prophylaxis with micafungin. His clinical status stabilized with broad anti-infective treatment and intensive supportive measures. An autologous stem cell backup was employed on day 46 to support hematopoietic recovery. Although the counts of the patient eventually started to recover, he developed an invasive pulmonary aspergillosis, which ultimately lead to respiratory failure and death. Postmortem examination revealed signs of Candida glabrata pancolitis.
CONCLUSIONS
This case highlights the increased risk for fatal infectious complications in patients who present with profound and prolonged cytopenia after CAR T-cell therapy. We describe a rare case of C. glabrata pancolitis associated with multifactorial immunosuppression. Although our patient succumbed to a fatal fungal infection, autologous stem cell boost was able to spur hematopoiesis and may represent an important therapeutic strategy for DLBCL patients with CAR T-cell associated bone marrow aplasia who have underwent prior stem cell harvest.
Background
When CD19-directed Chimeric Antigen Receptor (CAR) T-cell therapies were first introduced into the clinical setting, a set of distinctive side effects were observed, including Cytokine Release Syndrome (CRS) and immune effector cell-associated neurotoxicity syndrome (ICANS). As these treatments transition from large clinical trials to real-world implementation, new nuances of the side effect spectrum have emerged. This includes the observation that patients can present not only with grade 3–4 cytopenia (CTCAE v5.0), but also a syndrome of persistent cytopenia after CAR T-cell transfusion [1, 2]. Hematologic toxicity is common with one study demonstrating that neutropenia, thrombocytopenia and anemia occur in 94, 80 and 51% of patients respectively [3]. Risk factors for hematotoxicity include CRS grade, baseline cytopenia, and prior allogeneic stem cell transplantation within the last year [2, 3]. The fact that baseline hematopoietic reserve contributes to cytopenia in CAR T-cell patients may explain the variability in the incidence of hematoxicity in the real-world setting compared to the large registration trials, which set stringent hematologic exclusion criteria [4, 5]. The clinical utility of therapeutic rescue strategies that mitigate the risk of infectious complications secondary to long-term bone marrow (BM) aplasia, such as early autologous stem cell boost or Eltrombopag, remains unknown. Moreover, the relative paucity of reports concerning severe and life-threatening infections in the reported CD19-directed CAR T-cell trials necessitates the presentation of distinctive clinical courses that underline the risks of persistent cytopenia after CAR T-cell therapy in a real-world setting.
Case presentation
The 59-year-old male patient was initially diagnosed with stage IIIA follicular lymphoma in January 2018, which transformed to germinal center B-cell like DLBCL in October of the same year. Refractory to multiple cycles of Rituximab-based immunochemotherapy (Fig. 1a), the patient underwent leukapheresis for CAR T-cell therapy in April 2019. The patient experienced significant lymphoma progression during the manufacturing process of Axicabtagene ciloleucel (Axi-cel), manifesting itself in the form of malignant pleural effusions and progressive lymphadenopathy (Fig. 2a,c,e). In the six-week period between leukapheresis and lymphodepletion, the patient remained severely neutropenic after R-CHOP and developed possible invasive fungal disease (IFD) [6] (Fig. 3e) as well as E. coli septicemia secondary to a urinary tract infection. These infections were treated successfully with liposomal amphotericin B and piperacillin/tazobactam. Prior to lymphodepletion (D-5), the patient presented with an ECOG performance status of 1, intact renal and liver function, while observing residually depressed blood counts (WBC 1270/μl, ANC 700/μl, ALC 390/μl, Hemoglobin 7.2 g/dl, Platelets 20 G/l). BM histopathology showed a hypocellular marrow with no evidence of lymphoma infiltration. Analysis of lymphocyte subpopulations demonstrated severe B-cell aplasia and decreased absolute CD4+ (84/μl) and CD8+ (271/μl) counts. His anti-infective prophylaxis consisted of a combination of acyclovir, sulfamethoxazole/trimethoprim (TMP/SMZ), and posaconazole. The fludarabine/cyclophosphamide lympho-preparative regimen was applied on days − 5 to − 3 according to the provider’s protocol, followed by CAR T-cell transfusion on day 0.
Fig. 1 Overview of CAR T-cell mediated hematotoxicity and infectious complications. a Treatment course prior to CAR T-cell therapy. b Timeline of infectious complications during CAR T-cell treatment course. Positive microbiologic culture results are underlined. Bottom: Overview of utilized anti-infectives with the respective bars displaying the length of treatment. P/T = piperacillin/tazobactam, Ami = amikacin, Mero = meropenem, Vanco = vancomycin, Line = linezolid, Posa = posaconazole (p.o.), Mica = micafungin (i.v.), Amb = liposomal amphotericin B. The patient also received prophylactic acyclovir and sulfamethoxazole/trimethoprim (TMP/SMZ) during treatment. c Complete Blood Count (CBC) timeline. ANC (blue), platelet count (green), Hemoglobin (red). Transfusion events (green: platelet transfusion, red: pRBC transfusion) and G-CSF support (blue bar) are integrated in the curve. d Dynamics of Serum Inflammatory Markers. Infectious complications are superimposed above the graph. e Histopathologic analysis of BM biopsies demonstrating severe BM aplasia 1 month after CAR T-cell transfusion (Day 32, upper panel) and evidence of recovering hematopoiesis following autologous stem cell transfer (Autopsy, lower panel). Immunohistochemical staining for myeloperoxidase (= MPO) highlighting strong activation of myelopoiesis (right panel)
Fig. 2 Radiographic evidence of partial response to Axi-cel after 36 days. Contrast-enhanced CT abdomen (axial view) displaying pleural manifestations before (a) and after (b) CAR T-cell treatment. Involved paraaortic lymph nodes (red arrows) demonstrate an interval decrease in size (c-d, e-f). The inset of panel F depicts splenic hypodensities consistent with necrosis of tumor tissue secondary to immune therapy and a reduction of splenomegaly. G Graphical depiction of response over time. Tumor extent was quantified as the sum of the product of perpendicular diameters according to Lugano criteria over 3 time points and is graphed on the y-axis. H Timeline of LDH levels (U/l). The increase in LDH levels at day 25 correlated with the gastrointestinal toxicity and liver dysfunction
Fig. 3 Multi-organ toxicity secondary to CD19-directed CAR T-cell therapy. a Contrast-enhanced CT abdomen demonstrating a non-inflamed baseline state of GI mucosal tissue prior to CAR T therapy. b Panmural swelling of the sigma (left panel), ascending colon (middle panel), and stomach. c Non-pathologic CT of the brain. d Axial FLAIR-weighted (left), T1-weighted contrast-enhanced (middle), and diffusion-weighted (right) MRI displaying no evidence of cerebral edema, white matter lesions, diffusion restriction, microbleeds, meningeal enhancement or contrast enhancing lesions. e High-resolution CT thorax with bilateral fungal infiltrates observing the typical halo configuration 6 weeks prior to CAR T-cell transfusion. f On day − 3 the right-sided infiltrates have decreased in size. The left lung is collapsed due to malignant pleural effusion. g Lung parenchyma exhibiting an infiltration of non-dimorphic blastoconidial morphology consistent with Candida glabrata. h PAS staining of a lung specimen highlights septated hiphae and acute-angle branching, features consistent of with aspergillus infection
During lymphodepletion the patient developed an upper respiratory infection, presenting with a non-productive cough and a sputum culture positive for Bordetella bronchiseptica, which resolved clinically after antibiotic treatment with piperacillin/tazobactam. On day 7, the patient developed fever with a stable cardiopulmonary function and concomitant IL-6 rise (Fig. 1d), which was classified as CRS grade I according to ASTCT consensus grading [7] in the absence of positive blood cultures and other foci. Due to persistent fever refractory to antipyretic treatment, four total doses of tocilizumab (8 mg/kg) were applied over 36 h. Starting on day 9, the patient deteriorated neurologically with a depressed state of consciousness prompting the diagnosis of grade IV ICANS. The patient was transferred to the neurological ICU, and high-dose corticosteroids (methylprednisolone 1000 mg daily) were initiated. CSF-analysis displayed subtle pleocytosis, but revealed no signs of CNS infection (viral, bacterial and fungal) or meningeal involvement of the DLBCL. CT and MR imaging of the brain exhibited none of the pathological findings reported for ICANS [8] or CNS infection [9](Fig. 3c-d). After 5 days of high-dose methylprednisolone, the patient’s neurological status slowly improved, and corticosteroids could be tapered.
Partial response to Axicabtagene-Ciloleucel after 36 days according to Lugano criteria
While the patient’s initial clinical course was fraught with complications, CT staging performed at day 36 demonstrated a partial response to CAR T-cell therapy according to Lugano and Lyric criteria (Fig. 2a-g). This was particularly evident for the pleural manifestations of the underlying DLBCL, which was accompanied by an interval decrease in pleural effusions and subjective dyspnea (Fig. 2a-b). Multiple nodal sites including paraaortic (Fig. 2c-d) and parailiac lymph nodes (Fig. 2e-f) exhibited significant regression of tumor size (Fig. 2g). Moreover, the patient displayed splenic hypodensities consistent with either tumor tissue necrosis or infection-associated inflammatory changes (inset, Fig. 2f). These CT-morphologic findings were accompanied by a decrease of LDH levels (Fig. 2h).
Prolonged cytopenia lead to the development of severe neutropenic colitis and fatal fungal pneumonia
The patient presented with significant myelotoxicity and sustained transfusion dependency after CAR T-cell administration (Fig. 1c). The overall duration of profound neutropenia – defined as an ANC < 100/μl [10] – was 52 days. Because of the severity of ICANS, the clinicians chose to hold G-CSF during this time period due to concerns for risk of worsening toxicity [11].
While receiving broad anti-infectives (acyclovir, TMP/SMZ, posaconazole, meropenem), the patient developed breakthrough septic shock on day 24. He exhibited fever (39.5 °C), hypotension (70/30 mmHg), tachycardia (160/min), as well as lactic acidosis (lactate: 10.7 mmol/l). The patient was non-conversant, non-oriented, and was not able to localize symptoms. However, he had described epigastric tenderness and subtle changes in stool consistency and frequency on the previous day. As a result, abdominal CT imaging was obtained, which displayed severe pancolitis, as evidenced by pronounced mucosal thickening with edematous changes ranging from the ascending colon to the rectum (Fig. 3a-b). Labs were notable for an acute spike of serum inflammatory parameters (Il-6 > 500.000 pg/ml, CRP 5.7 mg/dl, Procalcitonin 11.2 ng/ml, Fig. 1d). Following ICU transfer, high-dose vasopressor support with norepinephrine was initiated together with volume resuscitation to maintain organ perfusion. Due to progressive loss of consciousness the patient was intubated and mechanically ventilated. To control the proinflammatory state, extracorporeal cytokine absorption (Cytosorb®) was performed, which resulted in a decrease of soluble inflammatory markers in the subsequent days. Arterial blood cultures were positive for vancomycin-resistant enterococci (VRE), and the antibiotic treatment was escalated to include linezolid along with meropenem (Fig. 1b). The ICU team transitioned antifungal prophylaxis from posaconazole to an echinocandine (micafungin 50 mg IV) due to ECG changes and concerns for drug interactions on day 24. Though he remained in critical condition, in the coming weeks his clinical condition stabilized and both the catecholamine rate and volume support could be reduced. To determine the origin of sustained myelosuppression, a bone marrow biopsy was obtained, which depicted a hypocellular marrow and severe aplasia affecting all hematopoietic lineages (Fig. 1e). On days 41 and 49, surveillance blood cultures were positive for Candida glabrata, a commensal fungal organism of human mucosal tissues [12] harboring an intrinsic azole resistance [13]. Susceptibility testing confirmed the azole-resistance of C. glabrata isolates. The antimycotic therapy was escalated from micafungin to liposomal amphotericin B. C. glabrata likely disseminated to the bloodstream secondary to the described gastrointestinal toxicity and was previously discovered on rectal swab (Fig. 1b) and fecal culture (day − 51).
Due to sustained neutropenia, BM aplasia and the availability of a suitable apheresis product, the CAR T-cell Taskforce proceeded with a stem cell boost of previously collected autologous CD34+ cells (3,1 × 106 cells) on day 46. The combination of a sudden rise in serum inflammatory markers and a strongly positive serum galactomannan (GM) assay on day 49 prompted diagnostic bronchoscopy, which revealed a diffuse infiltrate of alveolar and peri-bronchial tissue by Aspergillus fumigatus, consistent with fulminant invasive fungal pneumonia. Over the next week, the patient became increasingly hemodynamically unstable with poor peripheral oxygenation. Repeat bronchoscopy with bronchial lavage was positive for A. fumigatus and C. glabrata. After 50 days of G-CSF refractory aplasia, the autologous stem cells slowly engrafted leading to neutrophil recovery. However, this likely exacerbated the local inflammatory reaction in the lung, contributing to rapid deterioration of his respiratory status. Despite extensive supportive measures, the patient died on day 58 after CAR T-cell transfusion. Cause of death was confirmed by autopsy as invasive fungal pneumonia with multi-organ septic spread. Post-mortem examination revealed Candida spores in intestinal, colonic and rectal tissue. Of note, histopathologic BM analysis revealed signs of burgeoning hematopoietic regeneration (Fig. 1e).
Discussion and conclusions
Recent studies have shed light on the high incidence of prolonged and profound neutropenia after adoptive immunotherapy with CD19-specific CAR T-cells [1–3]. Clinical sequalae include severe infectious complications, which have emerged as the number one cause of long-term non-relapse mortality after CAR T-cell therapy [14]. In a seminal study, Hill and colleagues demonstrate that infectious complications are common with a cumulative incidence of 23% in the first 28 days after CAR T-cell transfusion and 14% between days 29–90. While bacterial infections were most common in the first month, viral infections – especially respiratory viruses – predominated after day 29, likely as a result of an impaired adaptive immune response due to B-cell aplasia [15]. Overall, most infections were mild to moderate and fatal infections were rare. Invasive mold infections were uncommon, ranging from 1 to 7% in CAR T-cell recipients [15–17]. In multivariate analyses, the use of systemic corticosteroids for the management of CRS or ICANS has emerged as a major risk factor of infection [18]. Certain inflammatory signatures – such as the “double peaks of IL-6” pattern observed in our patient – have been shown to confer an especially high risk of life-threatening infection [19].
This case highlights the combination of factors that precipitate a high risk of infectious complications in a CAR T-cell patient. First, the heavily pre-treated patient displayed B-cell aplasia and a diminished hematopoietic reserve (e.g. trilineage cytopenia) prior to lymphodepletion. Second, the patient developed classic complications of CAR T-cell therapy such as CRS and severe and prolonged ICANS, reflecting a pro-inflammatory state that represents an important risk factor for developing infections in CAR T-cell patients [16]. The subsequent application of high-dose corticosteroids impaired both innate and adaptive immunity [20]. Third, pancytopenia was profound, prolonged and not able to be reverted by growth factor support. Fourth, the patient had a history of infectious complications, including a course of fungal pneumonia 6 weeks prior to lymphodepletion, likely flaring up in the setting of the above three factors.
Our patient developed severe septic shock secondary to neutropenic colitis on day 24, highlighting the risk of a watch-and-wait approach to prolonged neutropenia after CAR T-cell therapy. A two-pronged approach to management appears prescient. On the one hand, measures to propagate hematopoietic recovery should be exhausted (causal therapy). This can range from G-CSF stimulation, to a trial of pulse-dose corticosteroids or anti-cytokine therapy (e.g. Anakinra, Tocilizumab), to a stem cell boost as a last resort in lymphoma patients who have undergone prior autologous stem cell transplantation. On the other hand, clinicians should be at high alert for infectious complications and adapt their infection surveillance and anti-infective prophylactic strategies accordingly. For example, therapeutic drug monitoring of posaconazole and meropenem levels may have revealed subtherapeutic dosing of these anti-infective agents in this patient [21]. The role of antifungal prophylaxis in the CAR T-cell patient remains inconclusive. Adequately powered studies addressing the duration of neutropenia after CAR T-cell therapy, and potential clinical determinants of invasive fungal infections, will be critical to gauge the benefit of antifungal prophylaxis in this patient collective.
Candida species are a leading cause of fungus-associated morbidity and mortality in severely immunocompromised patients [21]. On day 41, this patient developed breakthrough C. glabrata Candidemia on micafungin, in the setting of both underlying colonization and neutropenic colitis. A recent report implicated the gastrointestinal tract as major source of echinocandin drug resistance in a murine model of C. glabrata colonization and systemic dissemination [22]. Of note, breakthrough Candida infections on micafungin may occur at the employed dose level (50 mg/day IV), suggesting that this dose may have been inadequate to prevent subsequent Candidemia [23]. Though cases of C. glabrata colitis are extremely rare [24], an opportunistic infection could not be ruled out given that C. glabrata infiltrates were discovered in enteral and colonic mucosal tissue on post-mortem examination. Importantly, the patients’ clinical status deteriorated only after the stem cell boost resulted in signs of hematopoietic recovery. The paradoxical worsening of the pulmonary A. fumigatus infection is consistent with immune reconstitution inflammatory syndrome (IRIS), which has been previously described for HIV/AIDS [25] and for severely neutropenic patients with IPA [26]. In conclusion, this case emphasizes that infectious complications secondary to prolonged cytopenia influence non-relapse mortality after CAR T-cell therapy.
Abbreviations
ALCAbsolute Lymphocyte Count
ANCAbsolute Neutrophil Count
BMBone Marrow
CARChimeric antigen receptor
CBCComplete Blood Count
CRSCytokine release syndrome
CTCAECommon Terminology Criteria for Adverse Events
DLBCLDiffuse large B-cell lymphoma
FFPFresh frozen plasma
FLAIRFluid-attenuated inversion recovery
Flu/CyFludarabine/Cyclophosphamide
G-CSFGranulocyte colony stimulating factor
GIGastrointestinal
GMGalactomannan
HSPCsHematopoietic stem and progenitor cells
ICANSImmune effector cell-associated neurotoxicity syndrome
ICE-scoreImmune Effector Cell-associated Encephalopathy score
ICUIntensive care unit
IPAInvasive pulmonary aspergillosis
LDHLactate Dehydrogenase
LYRICLymphoma response to immunomodulatory therapy criteria
MDRDModification of Diet in Renal Disease
MPOMyeloperoxidase
PASPeriodic acid-Schiff
PBSCPeripheral Blood Stem Cell
VREVancomycin-resistant Enterococcus
WBCWhite Blood Count
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Acknowledgements
Not applicable.
Authors’ contributions
The original manuscript was written by KR. KR and WGK prepared the figures. MR performed the histological examination of the bone marrow. MS reviewed and edited the manuscript. The other authors (VB1, VB2, CS, PK, FS, KD, LvB, JS, OW, MD, MvBB) contributed to patient management and participated in drafting and editing the manuscript. All authors read and approved the final manuscript.
Funding
Not applicable. Open Access funding enabled and organized by Projekt DEAL.
Availability of data and materials
The authors did not use any database, software, or tools for the writing of this manuscript.
Ethics approval and consent to participate
The authors obtained consent from the deceased patient’s next-of-kin to participate.
Consent for publication
Written informed consent was obtained from the patient’s next-of-kin for publication of this Case report and any accompanying images. A copy of the written consent is available for review by the Editor of this journal.
Competing interests
The authors declare that they have no competing interests related with this case report. | CYCLOPHOSPHAMIDE, DOXORUBICIN HYDROCHLORIDE, METHYLPREDNISOLONE, PREDNISOLONE, RITUXIMAB, VINCRISTINE | DrugsGivenReaction | CC BY | 33509115 | 18,947,434 | 2021-01-28 |
Give an alphabetized list of all active substances of drugs taken by the patient who experienced 'Myelosuppression'. | Severe Candida glabrata pancolitis and fatal Aspergillus fumigatus pulmonary infection in the setting of bone marrow aplasia after CD19-directed CAR T-cell therapy - a case report.
BACKGROUND
Prolonged myelosuppression following CD19-directed CAR T-cell transfusion represents an important, yet underreported, adverse event. The resulting neutropenia and multifactorial immunosuppression can facilitate severe infectious complications.
METHODS
We describe the clinical course of a 59-year-old patient with relapsed/refractory DLBCL who received Axicabtagene-Ciloleucel (Axi-cel). The patient developed ASTCT grade I CRS and grade IV ICANS, necessitating admission to the neurological ICU and prolonged application of high-dose corticosteroids and other immunosuppressive agents. Importantly, neutropenia was profound (ANC < 100/μl), G-CSF-refractory, and prolonged, lasting more than 50 days. The patient developed severe septic shock 3 weeks after CAR transfusion while receiving anti-fungal prophylaxis with micafungin. His clinical status stabilized with broad anti-infective treatment and intensive supportive measures. An autologous stem cell backup was employed on day 46 to support hematopoietic recovery. Although the counts of the patient eventually started to recover, he developed an invasive pulmonary aspergillosis, which ultimately lead to respiratory failure and death. Postmortem examination revealed signs of Candida glabrata pancolitis.
CONCLUSIONS
This case highlights the increased risk for fatal infectious complications in patients who present with profound and prolonged cytopenia after CAR T-cell therapy. We describe a rare case of C. glabrata pancolitis associated with multifactorial immunosuppression. Although our patient succumbed to a fatal fungal infection, autologous stem cell boost was able to spur hematopoiesis and may represent an important therapeutic strategy for DLBCL patients with CAR T-cell associated bone marrow aplasia who have underwent prior stem cell harvest.
Background
When CD19-directed Chimeric Antigen Receptor (CAR) T-cell therapies were first introduced into the clinical setting, a set of distinctive side effects were observed, including Cytokine Release Syndrome (CRS) and immune effector cell-associated neurotoxicity syndrome (ICANS). As these treatments transition from large clinical trials to real-world implementation, new nuances of the side effect spectrum have emerged. This includes the observation that patients can present not only with grade 3–4 cytopenia (CTCAE v5.0), but also a syndrome of persistent cytopenia after CAR T-cell transfusion [1, 2]. Hematologic toxicity is common with one study demonstrating that neutropenia, thrombocytopenia and anemia occur in 94, 80 and 51% of patients respectively [3]. Risk factors for hematotoxicity include CRS grade, baseline cytopenia, and prior allogeneic stem cell transplantation within the last year [2, 3]. The fact that baseline hematopoietic reserve contributes to cytopenia in CAR T-cell patients may explain the variability in the incidence of hematoxicity in the real-world setting compared to the large registration trials, which set stringent hematologic exclusion criteria [4, 5]. The clinical utility of therapeutic rescue strategies that mitigate the risk of infectious complications secondary to long-term bone marrow (BM) aplasia, such as early autologous stem cell boost or Eltrombopag, remains unknown. Moreover, the relative paucity of reports concerning severe and life-threatening infections in the reported CD19-directed CAR T-cell trials necessitates the presentation of distinctive clinical courses that underline the risks of persistent cytopenia after CAR T-cell therapy in a real-world setting.
Case presentation
The 59-year-old male patient was initially diagnosed with stage IIIA follicular lymphoma in January 2018, which transformed to germinal center B-cell like DLBCL in October of the same year. Refractory to multiple cycles of Rituximab-based immunochemotherapy (Fig. 1a), the patient underwent leukapheresis for CAR T-cell therapy in April 2019. The patient experienced significant lymphoma progression during the manufacturing process of Axicabtagene ciloleucel (Axi-cel), manifesting itself in the form of malignant pleural effusions and progressive lymphadenopathy (Fig. 2a,c,e). In the six-week period between leukapheresis and lymphodepletion, the patient remained severely neutropenic after R-CHOP and developed possible invasive fungal disease (IFD) [6] (Fig. 3e) as well as E. coli septicemia secondary to a urinary tract infection. These infections were treated successfully with liposomal amphotericin B and piperacillin/tazobactam. Prior to lymphodepletion (D-5), the patient presented with an ECOG performance status of 1, intact renal and liver function, while observing residually depressed blood counts (WBC 1270/μl, ANC 700/μl, ALC 390/μl, Hemoglobin 7.2 g/dl, Platelets 20 G/l). BM histopathology showed a hypocellular marrow with no evidence of lymphoma infiltration. Analysis of lymphocyte subpopulations demonstrated severe B-cell aplasia and decreased absolute CD4+ (84/μl) and CD8+ (271/μl) counts. His anti-infective prophylaxis consisted of a combination of acyclovir, sulfamethoxazole/trimethoprim (TMP/SMZ), and posaconazole. The fludarabine/cyclophosphamide lympho-preparative regimen was applied on days − 5 to − 3 according to the provider’s protocol, followed by CAR T-cell transfusion on day 0.
Fig. 1 Overview of CAR T-cell mediated hematotoxicity and infectious complications. a Treatment course prior to CAR T-cell therapy. b Timeline of infectious complications during CAR T-cell treatment course. Positive microbiologic culture results are underlined. Bottom: Overview of utilized anti-infectives with the respective bars displaying the length of treatment. P/T = piperacillin/tazobactam, Ami = amikacin, Mero = meropenem, Vanco = vancomycin, Line = linezolid, Posa = posaconazole (p.o.), Mica = micafungin (i.v.), Amb = liposomal amphotericin B. The patient also received prophylactic acyclovir and sulfamethoxazole/trimethoprim (TMP/SMZ) during treatment. c Complete Blood Count (CBC) timeline. ANC (blue), platelet count (green), Hemoglobin (red). Transfusion events (green: platelet transfusion, red: pRBC transfusion) and G-CSF support (blue bar) are integrated in the curve. d Dynamics of Serum Inflammatory Markers. Infectious complications are superimposed above the graph. e Histopathologic analysis of BM biopsies demonstrating severe BM aplasia 1 month after CAR T-cell transfusion (Day 32, upper panel) and evidence of recovering hematopoiesis following autologous stem cell transfer (Autopsy, lower panel). Immunohistochemical staining for myeloperoxidase (= MPO) highlighting strong activation of myelopoiesis (right panel)
Fig. 2 Radiographic evidence of partial response to Axi-cel after 36 days. Contrast-enhanced CT abdomen (axial view) displaying pleural manifestations before (a) and after (b) CAR T-cell treatment. Involved paraaortic lymph nodes (red arrows) demonstrate an interval decrease in size (c-d, e-f). The inset of panel F depicts splenic hypodensities consistent with necrosis of tumor tissue secondary to immune therapy and a reduction of splenomegaly. G Graphical depiction of response over time. Tumor extent was quantified as the sum of the product of perpendicular diameters according to Lugano criteria over 3 time points and is graphed on the y-axis. H Timeline of LDH levels (U/l). The increase in LDH levels at day 25 correlated with the gastrointestinal toxicity and liver dysfunction
Fig. 3 Multi-organ toxicity secondary to CD19-directed CAR T-cell therapy. a Contrast-enhanced CT abdomen demonstrating a non-inflamed baseline state of GI mucosal tissue prior to CAR T therapy. b Panmural swelling of the sigma (left panel), ascending colon (middle panel), and stomach. c Non-pathologic CT of the brain. d Axial FLAIR-weighted (left), T1-weighted contrast-enhanced (middle), and diffusion-weighted (right) MRI displaying no evidence of cerebral edema, white matter lesions, diffusion restriction, microbleeds, meningeal enhancement or contrast enhancing lesions. e High-resolution CT thorax with bilateral fungal infiltrates observing the typical halo configuration 6 weeks prior to CAR T-cell transfusion. f On day − 3 the right-sided infiltrates have decreased in size. The left lung is collapsed due to malignant pleural effusion. g Lung parenchyma exhibiting an infiltration of non-dimorphic blastoconidial morphology consistent with Candida glabrata. h PAS staining of a lung specimen highlights septated hiphae and acute-angle branching, features consistent of with aspergillus infection
During lymphodepletion the patient developed an upper respiratory infection, presenting with a non-productive cough and a sputum culture positive for Bordetella bronchiseptica, which resolved clinically after antibiotic treatment with piperacillin/tazobactam. On day 7, the patient developed fever with a stable cardiopulmonary function and concomitant IL-6 rise (Fig. 1d), which was classified as CRS grade I according to ASTCT consensus grading [7] in the absence of positive blood cultures and other foci. Due to persistent fever refractory to antipyretic treatment, four total doses of tocilizumab (8 mg/kg) were applied over 36 h. Starting on day 9, the patient deteriorated neurologically with a depressed state of consciousness prompting the diagnosis of grade IV ICANS. The patient was transferred to the neurological ICU, and high-dose corticosteroids (methylprednisolone 1000 mg daily) were initiated. CSF-analysis displayed subtle pleocytosis, but revealed no signs of CNS infection (viral, bacterial and fungal) or meningeal involvement of the DLBCL. CT and MR imaging of the brain exhibited none of the pathological findings reported for ICANS [8] or CNS infection [9](Fig. 3c-d). After 5 days of high-dose methylprednisolone, the patient’s neurological status slowly improved, and corticosteroids could be tapered.
Partial response to Axicabtagene-Ciloleucel after 36 days according to Lugano criteria
While the patient’s initial clinical course was fraught with complications, CT staging performed at day 36 demonstrated a partial response to CAR T-cell therapy according to Lugano and Lyric criteria (Fig. 2a-g). This was particularly evident for the pleural manifestations of the underlying DLBCL, which was accompanied by an interval decrease in pleural effusions and subjective dyspnea (Fig. 2a-b). Multiple nodal sites including paraaortic (Fig. 2c-d) and parailiac lymph nodes (Fig. 2e-f) exhibited significant regression of tumor size (Fig. 2g). Moreover, the patient displayed splenic hypodensities consistent with either tumor tissue necrosis or infection-associated inflammatory changes (inset, Fig. 2f). These CT-morphologic findings were accompanied by a decrease of LDH levels (Fig. 2h).
Prolonged cytopenia lead to the development of severe neutropenic colitis and fatal fungal pneumonia
The patient presented with significant myelotoxicity and sustained transfusion dependency after CAR T-cell administration (Fig. 1c). The overall duration of profound neutropenia – defined as an ANC < 100/μl [10] – was 52 days. Because of the severity of ICANS, the clinicians chose to hold G-CSF during this time period due to concerns for risk of worsening toxicity [11].
While receiving broad anti-infectives (acyclovir, TMP/SMZ, posaconazole, meropenem), the patient developed breakthrough septic shock on day 24. He exhibited fever (39.5 °C), hypotension (70/30 mmHg), tachycardia (160/min), as well as lactic acidosis (lactate: 10.7 mmol/l). The patient was non-conversant, non-oriented, and was not able to localize symptoms. However, he had described epigastric tenderness and subtle changes in stool consistency and frequency on the previous day. As a result, abdominal CT imaging was obtained, which displayed severe pancolitis, as evidenced by pronounced mucosal thickening with edematous changes ranging from the ascending colon to the rectum (Fig. 3a-b). Labs were notable for an acute spike of serum inflammatory parameters (Il-6 > 500.000 pg/ml, CRP 5.7 mg/dl, Procalcitonin 11.2 ng/ml, Fig. 1d). Following ICU transfer, high-dose vasopressor support with norepinephrine was initiated together with volume resuscitation to maintain organ perfusion. Due to progressive loss of consciousness the patient was intubated and mechanically ventilated. To control the proinflammatory state, extracorporeal cytokine absorption (Cytosorb®) was performed, which resulted in a decrease of soluble inflammatory markers in the subsequent days. Arterial blood cultures were positive for vancomycin-resistant enterococci (VRE), and the antibiotic treatment was escalated to include linezolid along with meropenem (Fig. 1b). The ICU team transitioned antifungal prophylaxis from posaconazole to an echinocandine (micafungin 50 mg IV) due to ECG changes and concerns for drug interactions on day 24. Though he remained in critical condition, in the coming weeks his clinical condition stabilized and both the catecholamine rate and volume support could be reduced. To determine the origin of sustained myelosuppression, a bone marrow biopsy was obtained, which depicted a hypocellular marrow and severe aplasia affecting all hematopoietic lineages (Fig. 1e). On days 41 and 49, surveillance blood cultures were positive for Candida glabrata, a commensal fungal organism of human mucosal tissues [12] harboring an intrinsic azole resistance [13]. Susceptibility testing confirmed the azole-resistance of C. glabrata isolates. The antimycotic therapy was escalated from micafungin to liposomal amphotericin B. C. glabrata likely disseminated to the bloodstream secondary to the described gastrointestinal toxicity and was previously discovered on rectal swab (Fig. 1b) and fecal culture (day − 51).
Due to sustained neutropenia, BM aplasia and the availability of a suitable apheresis product, the CAR T-cell Taskforce proceeded with a stem cell boost of previously collected autologous CD34+ cells (3,1 × 106 cells) on day 46. The combination of a sudden rise in serum inflammatory markers and a strongly positive serum galactomannan (GM) assay on day 49 prompted diagnostic bronchoscopy, which revealed a diffuse infiltrate of alveolar and peri-bronchial tissue by Aspergillus fumigatus, consistent with fulminant invasive fungal pneumonia. Over the next week, the patient became increasingly hemodynamically unstable with poor peripheral oxygenation. Repeat bronchoscopy with bronchial lavage was positive for A. fumigatus and C. glabrata. After 50 days of G-CSF refractory aplasia, the autologous stem cells slowly engrafted leading to neutrophil recovery. However, this likely exacerbated the local inflammatory reaction in the lung, contributing to rapid deterioration of his respiratory status. Despite extensive supportive measures, the patient died on day 58 after CAR T-cell transfusion. Cause of death was confirmed by autopsy as invasive fungal pneumonia with multi-organ septic spread. Post-mortem examination revealed Candida spores in intestinal, colonic and rectal tissue. Of note, histopathologic BM analysis revealed signs of burgeoning hematopoietic regeneration (Fig. 1e).
Discussion and conclusions
Recent studies have shed light on the high incidence of prolonged and profound neutropenia after adoptive immunotherapy with CD19-specific CAR T-cells [1–3]. Clinical sequalae include severe infectious complications, which have emerged as the number one cause of long-term non-relapse mortality after CAR T-cell therapy [14]. In a seminal study, Hill and colleagues demonstrate that infectious complications are common with a cumulative incidence of 23% in the first 28 days after CAR T-cell transfusion and 14% between days 29–90. While bacterial infections were most common in the first month, viral infections – especially respiratory viruses – predominated after day 29, likely as a result of an impaired adaptive immune response due to B-cell aplasia [15]. Overall, most infections were mild to moderate and fatal infections were rare. Invasive mold infections were uncommon, ranging from 1 to 7% in CAR T-cell recipients [15–17]. In multivariate analyses, the use of systemic corticosteroids for the management of CRS or ICANS has emerged as a major risk factor of infection [18]. Certain inflammatory signatures – such as the “double peaks of IL-6” pattern observed in our patient – have been shown to confer an especially high risk of life-threatening infection [19].
This case highlights the combination of factors that precipitate a high risk of infectious complications in a CAR T-cell patient. First, the heavily pre-treated patient displayed B-cell aplasia and a diminished hematopoietic reserve (e.g. trilineage cytopenia) prior to lymphodepletion. Second, the patient developed classic complications of CAR T-cell therapy such as CRS and severe and prolonged ICANS, reflecting a pro-inflammatory state that represents an important risk factor for developing infections in CAR T-cell patients [16]. The subsequent application of high-dose corticosteroids impaired both innate and adaptive immunity [20]. Third, pancytopenia was profound, prolonged and not able to be reverted by growth factor support. Fourth, the patient had a history of infectious complications, including a course of fungal pneumonia 6 weeks prior to lymphodepletion, likely flaring up in the setting of the above three factors.
Our patient developed severe septic shock secondary to neutropenic colitis on day 24, highlighting the risk of a watch-and-wait approach to prolonged neutropenia after CAR T-cell therapy. A two-pronged approach to management appears prescient. On the one hand, measures to propagate hematopoietic recovery should be exhausted (causal therapy). This can range from G-CSF stimulation, to a trial of pulse-dose corticosteroids or anti-cytokine therapy (e.g. Anakinra, Tocilizumab), to a stem cell boost as a last resort in lymphoma patients who have undergone prior autologous stem cell transplantation. On the other hand, clinicians should be at high alert for infectious complications and adapt their infection surveillance and anti-infective prophylactic strategies accordingly. For example, therapeutic drug monitoring of posaconazole and meropenem levels may have revealed subtherapeutic dosing of these anti-infective agents in this patient [21]. The role of antifungal prophylaxis in the CAR T-cell patient remains inconclusive. Adequately powered studies addressing the duration of neutropenia after CAR T-cell therapy, and potential clinical determinants of invasive fungal infections, will be critical to gauge the benefit of antifungal prophylaxis in this patient collective.
Candida species are a leading cause of fungus-associated morbidity and mortality in severely immunocompromised patients [21]. On day 41, this patient developed breakthrough C. glabrata Candidemia on micafungin, in the setting of both underlying colonization and neutropenic colitis. A recent report implicated the gastrointestinal tract as major source of echinocandin drug resistance in a murine model of C. glabrata colonization and systemic dissemination [22]. Of note, breakthrough Candida infections on micafungin may occur at the employed dose level (50 mg/day IV), suggesting that this dose may have been inadequate to prevent subsequent Candidemia [23]. Though cases of C. glabrata colitis are extremely rare [24], an opportunistic infection could not be ruled out given that C. glabrata infiltrates were discovered in enteral and colonic mucosal tissue on post-mortem examination. Importantly, the patients’ clinical status deteriorated only after the stem cell boost resulted in signs of hematopoietic recovery. The paradoxical worsening of the pulmonary A. fumigatus infection is consistent with immune reconstitution inflammatory syndrome (IRIS), which has been previously described for HIV/AIDS [25] and for severely neutropenic patients with IPA [26]. In conclusion, this case emphasizes that infectious complications secondary to prolonged cytopenia influence non-relapse mortality after CAR T-cell therapy.
Abbreviations
ALCAbsolute Lymphocyte Count
ANCAbsolute Neutrophil Count
BMBone Marrow
CARChimeric antigen receptor
CBCComplete Blood Count
CRSCytokine release syndrome
CTCAECommon Terminology Criteria for Adverse Events
DLBCLDiffuse large B-cell lymphoma
FFPFresh frozen plasma
FLAIRFluid-attenuated inversion recovery
Flu/CyFludarabine/Cyclophosphamide
G-CSFGranulocyte colony stimulating factor
GIGastrointestinal
GMGalactomannan
HSPCsHematopoietic stem and progenitor cells
ICANSImmune effector cell-associated neurotoxicity syndrome
ICE-scoreImmune Effector Cell-associated Encephalopathy score
ICUIntensive care unit
IPAInvasive pulmonary aspergillosis
LDHLactate Dehydrogenase
LYRICLymphoma response to immunomodulatory therapy criteria
MDRDModification of Diet in Renal Disease
MPOMyeloperoxidase
PASPeriodic acid-Schiff
PBSCPeripheral Blood Stem Cell
VREVancomycin-resistant Enterococcus
WBCWhite Blood Count
Publisher’s Note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
Acknowledgements
Not applicable.
Authors’ contributions
The original manuscript was written by KR. KR and WGK prepared the figures. MR performed the histological examination of the bone marrow. MS reviewed and edited the manuscript. The other authors (VB1, VB2, CS, PK, FS, KD, LvB, JS, OW, MD, MvBB) contributed to patient management and participated in drafting and editing the manuscript. All authors read and approved the final manuscript.
Funding
Not applicable. Open Access funding enabled and organized by Projekt DEAL.
Availability of data and materials
The authors did not use any database, software, or tools for the writing of this manuscript.
Ethics approval and consent to participate
The authors obtained consent from the deceased patient’s next-of-kin to participate.
Consent for publication
Written informed consent was obtained from the patient’s next-of-kin for publication of this Case report and any accompanying images. A copy of the written consent is available for review by the Editor of this journal.
Competing interests
The authors declare that they have no competing interests related with this case report. | CYCLOPHOSPHAMIDE, DOXORUBICIN HYDROCHLORIDE, METHYLPREDNISOLONE, PREDNISOLONE, RITUXIMAB, VINCRISTINE | DrugsGivenReaction | CC BY | 33509115 | 18,947,434 | 2021-01-28 |
Give an alphabetized list of all active substances of drugs taken by the patient who experienced 'Neutropenia'. | Severe Candida glabrata pancolitis and fatal Aspergillus fumigatus pulmonary infection in the setting of bone marrow aplasia after CD19-directed CAR T-cell therapy - a case report.
BACKGROUND
Prolonged myelosuppression following CD19-directed CAR T-cell transfusion represents an important, yet underreported, adverse event. The resulting neutropenia and multifactorial immunosuppression can facilitate severe infectious complications.
METHODS
We describe the clinical course of a 59-year-old patient with relapsed/refractory DLBCL who received Axicabtagene-Ciloleucel (Axi-cel). The patient developed ASTCT grade I CRS and grade IV ICANS, necessitating admission to the neurological ICU and prolonged application of high-dose corticosteroids and other immunosuppressive agents. Importantly, neutropenia was profound (ANC < 100/μl), G-CSF-refractory, and prolonged, lasting more than 50 days. The patient developed severe septic shock 3 weeks after CAR transfusion while receiving anti-fungal prophylaxis with micafungin. His clinical status stabilized with broad anti-infective treatment and intensive supportive measures. An autologous stem cell backup was employed on day 46 to support hematopoietic recovery. Although the counts of the patient eventually started to recover, he developed an invasive pulmonary aspergillosis, which ultimately lead to respiratory failure and death. Postmortem examination revealed signs of Candida glabrata pancolitis.
CONCLUSIONS
This case highlights the increased risk for fatal infectious complications in patients who present with profound and prolonged cytopenia after CAR T-cell therapy. We describe a rare case of C. glabrata pancolitis associated with multifactorial immunosuppression. Although our patient succumbed to a fatal fungal infection, autologous stem cell boost was able to spur hematopoiesis and may represent an important therapeutic strategy for DLBCL patients with CAR T-cell associated bone marrow aplasia who have underwent prior stem cell harvest.
Background
When CD19-directed Chimeric Antigen Receptor (CAR) T-cell therapies were first introduced into the clinical setting, a set of distinctive side effects were observed, including Cytokine Release Syndrome (CRS) and immune effector cell-associated neurotoxicity syndrome (ICANS). As these treatments transition from large clinical trials to real-world implementation, new nuances of the side effect spectrum have emerged. This includes the observation that patients can present not only with grade 3–4 cytopenia (CTCAE v5.0), but also a syndrome of persistent cytopenia after CAR T-cell transfusion [1, 2]. Hematologic toxicity is common with one study demonstrating that neutropenia, thrombocytopenia and anemia occur in 94, 80 and 51% of patients respectively [3]. Risk factors for hematotoxicity include CRS grade, baseline cytopenia, and prior allogeneic stem cell transplantation within the last year [2, 3]. The fact that baseline hematopoietic reserve contributes to cytopenia in CAR T-cell patients may explain the variability in the incidence of hematoxicity in the real-world setting compared to the large registration trials, which set stringent hematologic exclusion criteria [4, 5]. The clinical utility of therapeutic rescue strategies that mitigate the risk of infectious complications secondary to long-term bone marrow (BM) aplasia, such as early autologous stem cell boost or Eltrombopag, remains unknown. Moreover, the relative paucity of reports concerning severe and life-threatening infections in the reported CD19-directed CAR T-cell trials necessitates the presentation of distinctive clinical courses that underline the risks of persistent cytopenia after CAR T-cell therapy in a real-world setting.
Case presentation
The 59-year-old male patient was initially diagnosed with stage IIIA follicular lymphoma in January 2018, which transformed to germinal center B-cell like DLBCL in October of the same year. Refractory to multiple cycles of Rituximab-based immunochemotherapy (Fig. 1a), the patient underwent leukapheresis for CAR T-cell therapy in April 2019. The patient experienced significant lymphoma progression during the manufacturing process of Axicabtagene ciloleucel (Axi-cel), manifesting itself in the form of malignant pleural effusions and progressive lymphadenopathy (Fig. 2a,c,e). In the six-week period between leukapheresis and lymphodepletion, the patient remained severely neutropenic after R-CHOP and developed possible invasive fungal disease (IFD) [6] (Fig. 3e) as well as E. coli septicemia secondary to a urinary tract infection. These infections were treated successfully with liposomal amphotericin B and piperacillin/tazobactam. Prior to lymphodepletion (D-5), the patient presented with an ECOG performance status of 1, intact renal and liver function, while observing residually depressed blood counts (WBC 1270/μl, ANC 700/μl, ALC 390/μl, Hemoglobin 7.2 g/dl, Platelets 20 G/l). BM histopathology showed a hypocellular marrow with no evidence of lymphoma infiltration. Analysis of lymphocyte subpopulations demonstrated severe B-cell aplasia and decreased absolute CD4+ (84/μl) and CD8+ (271/μl) counts. His anti-infective prophylaxis consisted of a combination of acyclovir, sulfamethoxazole/trimethoprim (TMP/SMZ), and posaconazole. The fludarabine/cyclophosphamide lympho-preparative regimen was applied on days − 5 to − 3 according to the provider’s protocol, followed by CAR T-cell transfusion on day 0.
Fig. 1 Overview of CAR T-cell mediated hematotoxicity and infectious complications. a Treatment course prior to CAR T-cell therapy. b Timeline of infectious complications during CAR T-cell treatment course. Positive microbiologic culture results are underlined. Bottom: Overview of utilized anti-infectives with the respective bars displaying the length of treatment. P/T = piperacillin/tazobactam, Ami = amikacin, Mero = meropenem, Vanco = vancomycin, Line = linezolid, Posa = posaconazole (p.o.), Mica = micafungin (i.v.), Amb = liposomal amphotericin B. The patient also received prophylactic acyclovir and sulfamethoxazole/trimethoprim (TMP/SMZ) during treatment. c Complete Blood Count (CBC) timeline. ANC (blue), platelet count (green), Hemoglobin (red). Transfusion events (green: platelet transfusion, red: pRBC transfusion) and G-CSF support (blue bar) are integrated in the curve. d Dynamics of Serum Inflammatory Markers. Infectious complications are superimposed above the graph. e Histopathologic analysis of BM biopsies demonstrating severe BM aplasia 1 month after CAR T-cell transfusion (Day 32, upper panel) and evidence of recovering hematopoiesis following autologous stem cell transfer (Autopsy, lower panel). Immunohistochemical staining for myeloperoxidase (= MPO) highlighting strong activation of myelopoiesis (right panel)
Fig. 2 Radiographic evidence of partial response to Axi-cel after 36 days. Contrast-enhanced CT abdomen (axial view) displaying pleural manifestations before (a) and after (b) CAR T-cell treatment. Involved paraaortic lymph nodes (red arrows) demonstrate an interval decrease in size (c-d, e-f). The inset of panel F depicts splenic hypodensities consistent with necrosis of tumor tissue secondary to immune therapy and a reduction of splenomegaly. G Graphical depiction of response over time. Tumor extent was quantified as the sum of the product of perpendicular diameters according to Lugano criteria over 3 time points and is graphed on the y-axis. H Timeline of LDH levels (U/l). The increase in LDH levels at day 25 correlated with the gastrointestinal toxicity and liver dysfunction
Fig. 3 Multi-organ toxicity secondary to CD19-directed CAR T-cell therapy. a Contrast-enhanced CT abdomen demonstrating a non-inflamed baseline state of GI mucosal tissue prior to CAR T therapy. b Panmural swelling of the sigma (left panel), ascending colon (middle panel), and stomach. c Non-pathologic CT of the brain. d Axial FLAIR-weighted (left), T1-weighted contrast-enhanced (middle), and diffusion-weighted (right) MRI displaying no evidence of cerebral edema, white matter lesions, diffusion restriction, microbleeds, meningeal enhancement or contrast enhancing lesions. e High-resolution CT thorax with bilateral fungal infiltrates observing the typical halo configuration 6 weeks prior to CAR T-cell transfusion. f On day − 3 the right-sided infiltrates have decreased in size. The left lung is collapsed due to malignant pleural effusion. g Lung parenchyma exhibiting an infiltration of non-dimorphic blastoconidial morphology consistent with Candida glabrata. h PAS staining of a lung specimen highlights septated hiphae and acute-angle branching, features consistent of with aspergillus infection
During lymphodepletion the patient developed an upper respiratory infection, presenting with a non-productive cough and a sputum culture positive for Bordetella bronchiseptica, which resolved clinically after antibiotic treatment with piperacillin/tazobactam. On day 7, the patient developed fever with a stable cardiopulmonary function and concomitant IL-6 rise (Fig. 1d), which was classified as CRS grade I according to ASTCT consensus grading [7] in the absence of positive blood cultures and other foci. Due to persistent fever refractory to antipyretic treatment, four total doses of tocilizumab (8 mg/kg) were applied over 36 h. Starting on day 9, the patient deteriorated neurologically with a depressed state of consciousness prompting the diagnosis of grade IV ICANS. The patient was transferred to the neurological ICU, and high-dose corticosteroids (methylprednisolone 1000 mg daily) were initiated. CSF-analysis displayed subtle pleocytosis, but revealed no signs of CNS infection (viral, bacterial and fungal) or meningeal involvement of the DLBCL. CT and MR imaging of the brain exhibited none of the pathological findings reported for ICANS [8] or CNS infection [9](Fig. 3c-d). After 5 days of high-dose methylprednisolone, the patient’s neurological status slowly improved, and corticosteroids could be tapered.
Partial response to Axicabtagene-Ciloleucel after 36 days according to Lugano criteria
While the patient’s initial clinical course was fraught with complications, CT staging performed at day 36 demonstrated a partial response to CAR T-cell therapy according to Lugano and Lyric criteria (Fig. 2a-g). This was particularly evident for the pleural manifestations of the underlying DLBCL, which was accompanied by an interval decrease in pleural effusions and subjective dyspnea (Fig. 2a-b). Multiple nodal sites including paraaortic (Fig. 2c-d) and parailiac lymph nodes (Fig. 2e-f) exhibited significant regression of tumor size (Fig. 2g). Moreover, the patient displayed splenic hypodensities consistent with either tumor tissue necrosis or infection-associated inflammatory changes (inset, Fig. 2f). These CT-morphologic findings were accompanied by a decrease of LDH levels (Fig. 2h).
Prolonged cytopenia lead to the development of severe neutropenic colitis and fatal fungal pneumonia
The patient presented with significant myelotoxicity and sustained transfusion dependency after CAR T-cell administration (Fig. 1c). The overall duration of profound neutropenia – defined as an ANC < 100/μl [10] – was 52 days. Because of the severity of ICANS, the clinicians chose to hold G-CSF during this time period due to concerns for risk of worsening toxicity [11].
While receiving broad anti-infectives (acyclovir, TMP/SMZ, posaconazole, meropenem), the patient developed breakthrough septic shock on day 24. He exhibited fever (39.5 °C), hypotension (70/30 mmHg), tachycardia (160/min), as well as lactic acidosis (lactate: 10.7 mmol/l). The patient was non-conversant, non-oriented, and was not able to localize symptoms. However, he had described epigastric tenderness and subtle changes in stool consistency and frequency on the previous day. As a result, abdominal CT imaging was obtained, which displayed severe pancolitis, as evidenced by pronounced mucosal thickening with edematous changes ranging from the ascending colon to the rectum (Fig. 3a-b). Labs were notable for an acute spike of serum inflammatory parameters (Il-6 > 500.000 pg/ml, CRP 5.7 mg/dl, Procalcitonin 11.2 ng/ml, Fig. 1d). Following ICU transfer, high-dose vasopressor support with norepinephrine was initiated together with volume resuscitation to maintain organ perfusion. Due to progressive loss of consciousness the patient was intubated and mechanically ventilated. To control the proinflammatory state, extracorporeal cytokine absorption (Cytosorb®) was performed, which resulted in a decrease of soluble inflammatory markers in the subsequent days. Arterial blood cultures were positive for vancomycin-resistant enterococci (VRE), and the antibiotic treatment was escalated to include linezolid along with meropenem (Fig. 1b). The ICU team transitioned antifungal prophylaxis from posaconazole to an echinocandine (micafungin 50 mg IV) due to ECG changes and concerns for drug interactions on day 24. Though he remained in critical condition, in the coming weeks his clinical condition stabilized and both the catecholamine rate and volume support could be reduced. To determine the origin of sustained myelosuppression, a bone marrow biopsy was obtained, which depicted a hypocellular marrow and severe aplasia affecting all hematopoietic lineages (Fig. 1e). On days 41 and 49, surveillance blood cultures were positive for Candida glabrata, a commensal fungal organism of human mucosal tissues [12] harboring an intrinsic azole resistance [13]. Susceptibility testing confirmed the azole-resistance of C. glabrata isolates. The antimycotic therapy was escalated from micafungin to liposomal amphotericin B. C. glabrata likely disseminated to the bloodstream secondary to the described gastrointestinal toxicity and was previously discovered on rectal swab (Fig. 1b) and fecal culture (day − 51).
Due to sustained neutropenia, BM aplasia and the availability of a suitable apheresis product, the CAR T-cell Taskforce proceeded with a stem cell boost of previously collected autologous CD34+ cells (3,1 × 106 cells) on day 46. The combination of a sudden rise in serum inflammatory markers and a strongly positive serum galactomannan (GM) assay on day 49 prompted diagnostic bronchoscopy, which revealed a diffuse infiltrate of alveolar and peri-bronchial tissue by Aspergillus fumigatus, consistent with fulminant invasive fungal pneumonia. Over the next week, the patient became increasingly hemodynamically unstable with poor peripheral oxygenation. Repeat bronchoscopy with bronchial lavage was positive for A. fumigatus and C. glabrata. After 50 days of G-CSF refractory aplasia, the autologous stem cells slowly engrafted leading to neutrophil recovery. However, this likely exacerbated the local inflammatory reaction in the lung, contributing to rapid deterioration of his respiratory status. Despite extensive supportive measures, the patient died on day 58 after CAR T-cell transfusion. Cause of death was confirmed by autopsy as invasive fungal pneumonia with multi-organ septic spread. Post-mortem examination revealed Candida spores in intestinal, colonic and rectal tissue. Of note, histopathologic BM analysis revealed signs of burgeoning hematopoietic regeneration (Fig. 1e).
Discussion and conclusions
Recent studies have shed light on the high incidence of prolonged and profound neutropenia after adoptive immunotherapy with CD19-specific CAR T-cells [1–3]. Clinical sequalae include severe infectious complications, which have emerged as the number one cause of long-term non-relapse mortality after CAR T-cell therapy [14]. In a seminal study, Hill and colleagues demonstrate that infectious complications are common with a cumulative incidence of 23% in the first 28 days after CAR T-cell transfusion and 14% between days 29–90. While bacterial infections were most common in the first month, viral infections – especially respiratory viruses – predominated after day 29, likely as a result of an impaired adaptive immune response due to B-cell aplasia [15]. Overall, most infections were mild to moderate and fatal infections were rare. Invasive mold infections were uncommon, ranging from 1 to 7% in CAR T-cell recipients [15–17]. In multivariate analyses, the use of systemic corticosteroids for the management of CRS or ICANS has emerged as a major risk factor of infection [18]. Certain inflammatory signatures – such as the “double peaks of IL-6” pattern observed in our patient – have been shown to confer an especially high risk of life-threatening infection [19].
This case highlights the combination of factors that precipitate a high risk of infectious complications in a CAR T-cell patient. First, the heavily pre-treated patient displayed B-cell aplasia and a diminished hematopoietic reserve (e.g. trilineage cytopenia) prior to lymphodepletion. Second, the patient developed classic complications of CAR T-cell therapy such as CRS and severe and prolonged ICANS, reflecting a pro-inflammatory state that represents an important risk factor for developing infections in CAR T-cell patients [16]. The subsequent application of high-dose corticosteroids impaired both innate and adaptive immunity [20]. Third, pancytopenia was profound, prolonged and not able to be reverted by growth factor support. Fourth, the patient had a history of infectious complications, including a course of fungal pneumonia 6 weeks prior to lymphodepletion, likely flaring up in the setting of the above three factors.
Our patient developed severe septic shock secondary to neutropenic colitis on day 24, highlighting the risk of a watch-and-wait approach to prolonged neutropenia after CAR T-cell therapy. A two-pronged approach to management appears prescient. On the one hand, measures to propagate hematopoietic recovery should be exhausted (causal therapy). This can range from G-CSF stimulation, to a trial of pulse-dose corticosteroids or anti-cytokine therapy (e.g. Anakinra, Tocilizumab), to a stem cell boost as a last resort in lymphoma patients who have undergone prior autologous stem cell transplantation. On the other hand, clinicians should be at high alert for infectious complications and adapt their infection surveillance and anti-infective prophylactic strategies accordingly. For example, therapeutic drug monitoring of posaconazole and meropenem levels may have revealed subtherapeutic dosing of these anti-infective agents in this patient [21]. The role of antifungal prophylaxis in the CAR T-cell patient remains inconclusive. Adequately powered studies addressing the duration of neutropenia after CAR T-cell therapy, and potential clinical determinants of invasive fungal infections, will be critical to gauge the benefit of antifungal prophylaxis in this patient collective.
Candida species are a leading cause of fungus-associated morbidity and mortality in severely immunocompromised patients [21]. On day 41, this patient developed breakthrough C. glabrata Candidemia on micafungin, in the setting of both underlying colonization and neutropenic colitis. A recent report implicated the gastrointestinal tract as major source of echinocandin drug resistance in a murine model of C. glabrata colonization and systemic dissemination [22]. Of note, breakthrough Candida infections on micafungin may occur at the employed dose level (50 mg/day IV), suggesting that this dose may have been inadequate to prevent subsequent Candidemia [23]. Though cases of C. glabrata colitis are extremely rare [24], an opportunistic infection could not be ruled out given that C. glabrata infiltrates were discovered in enteral and colonic mucosal tissue on post-mortem examination. Importantly, the patients’ clinical status deteriorated only after the stem cell boost resulted in signs of hematopoietic recovery. The paradoxical worsening of the pulmonary A. fumigatus infection is consistent with immune reconstitution inflammatory syndrome (IRIS), which has been previously described for HIV/AIDS [25] and for severely neutropenic patients with IPA [26]. In conclusion, this case emphasizes that infectious complications secondary to prolonged cytopenia influence non-relapse mortality after CAR T-cell therapy.
Abbreviations
ALCAbsolute Lymphocyte Count
ANCAbsolute Neutrophil Count
BMBone Marrow
CARChimeric antigen receptor
CBCComplete Blood Count
CRSCytokine release syndrome
CTCAECommon Terminology Criteria for Adverse Events
DLBCLDiffuse large B-cell lymphoma
FFPFresh frozen plasma
FLAIRFluid-attenuated inversion recovery
Flu/CyFludarabine/Cyclophosphamide
G-CSFGranulocyte colony stimulating factor
GIGastrointestinal
GMGalactomannan
HSPCsHematopoietic stem and progenitor cells
ICANSImmune effector cell-associated neurotoxicity syndrome
ICE-scoreImmune Effector Cell-associated Encephalopathy score
ICUIntensive care unit
IPAInvasive pulmonary aspergillosis
LDHLactate Dehydrogenase
LYRICLymphoma response to immunomodulatory therapy criteria
MDRDModification of Diet in Renal Disease
MPOMyeloperoxidase
PASPeriodic acid-Schiff
PBSCPeripheral Blood Stem Cell
VREVancomycin-resistant Enterococcus
WBCWhite Blood Count
Publisher’s Note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
Acknowledgements
Not applicable.
Authors’ contributions
The original manuscript was written by KR. KR and WGK prepared the figures. MR performed the histological examination of the bone marrow. MS reviewed and edited the manuscript. The other authors (VB1, VB2, CS, PK, FS, KD, LvB, JS, OW, MD, MvBB) contributed to patient management and participated in drafting and editing the manuscript. All authors read and approved the final manuscript.
Funding
Not applicable. Open Access funding enabled and organized by Projekt DEAL.
Availability of data and materials
The authors did not use any database, software, or tools for the writing of this manuscript.
Ethics approval and consent to participate
The authors obtained consent from the deceased patient’s next-of-kin to participate.
Consent for publication
Written informed consent was obtained from the patient’s next-of-kin for publication of this Case report and any accompanying images. A copy of the written consent is available for review by the Editor of this journal.
Competing interests
The authors declare that they have no competing interests related with this case report. | CYCLOPHOSPHAMIDE, DOXORUBICIN HYDROCHLORIDE, METHYLPREDNISOLONE, PREDNISOLONE, RITUXIMAB, VINCRISTINE | DrugsGivenReaction | CC BY | 33509115 | 18,947,434 | 2021-01-28 |
Give an alphabetized list of all active substances of drugs taken by the patient who experienced 'Pneumonia fungal'. | Severe Candida glabrata pancolitis and fatal Aspergillus fumigatus pulmonary infection in the setting of bone marrow aplasia after CD19-directed CAR T-cell therapy - a case report.
BACKGROUND
Prolonged myelosuppression following CD19-directed CAR T-cell transfusion represents an important, yet underreported, adverse event. The resulting neutropenia and multifactorial immunosuppression can facilitate severe infectious complications.
METHODS
We describe the clinical course of a 59-year-old patient with relapsed/refractory DLBCL who received Axicabtagene-Ciloleucel (Axi-cel). The patient developed ASTCT grade I CRS and grade IV ICANS, necessitating admission to the neurological ICU and prolonged application of high-dose corticosteroids and other immunosuppressive agents. Importantly, neutropenia was profound (ANC < 100/μl), G-CSF-refractory, and prolonged, lasting more than 50 days. The patient developed severe septic shock 3 weeks after CAR transfusion while receiving anti-fungal prophylaxis with micafungin. His clinical status stabilized with broad anti-infective treatment and intensive supportive measures. An autologous stem cell backup was employed on day 46 to support hematopoietic recovery. Although the counts of the patient eventually started to recover, he developed an invasive pulmonary aspergillosis, which ultimately lead to respiratory failure and death. Postmortem examination revealed signs of Candida glabrata pancolitis.
CONCLUSIONS
This case highlights the increased risk for fatal infectious complications in patients who present with profound and prolonged cytopenia after CAR T-cell therapy. We describe a rare case of C. glabrata pancolitis associated with multifactorial immunosuppression. Although our patient succumbed to a fatal fungal infection, autologous stem cell boost was able to spur hematopoiesis and may represent an important therapeutic strategy for DLBCL patients with CAR T-cell associated bone marrow aplasia who have underwent prior stem cell harvest.
Background
When CD19-directed Chimeric Antigen Receptor (CAR) T-cell therapies were first introduced into the clinical setting, a set of distinctive side effects were observed, including Cytokine Release Syndrome (CRS) and immune effector cell-associated neurotoxicity syndrome (ICANS). As these treatments transition from large clinical trials to real-world implementation, new nuances of the side effect spectrum have emerged. This includes the observation that patients can present not only with grade 3–4 cytopenia (CTCAE v5.0), but also a syndrome of persistent cytopenia after CAR T-cell transfusion [1, 2]. Hematologic toxicity is common with one study demonstrating that neutropenia, thrombocytopenia and anemia occur in 94, 80 and 51% of patients respectively [3]. Risk factors for hematotoxicity include CRS grade, baseline cytopenia, and prior allogeneic stem cell transplantation within the last year [2, 3]. The fact that baseline hematopoietic reserve contributes to cytopenia in CAR T-cell patients may explain the variability in the incidence of hematoxicity in the real-world setting compared to the large registration trials, which set stringent hematologic exclusion criteria [4, 5]. The clinical utility of therapeutic rescue strategies that mitigate the risk of infectious complications secondary to long-term bone marrow (BM) aplasia, such as early autologous stem cell boost or Eltrombopag, remains unknown. Moreover, the relative paucity of reports concerning severe and life-threatening infections in the reported CD19-directed CAR T-cell trials necessitates the presentation of distinctive clinical courses that underline the risks of persistent cytopenia after CAR T-cell therapy in a real-world setting.
Case presentation
The 59-year-old male patient was initially diagnosed with stage IIIA follicular lymphoma in January 2018, which transformed to germinal center B-cell like DLBCL in October of the same year. Refractory to multiple cycles of Rituximab-based immunochemotherapy (Fig. 1a), the patient underwent leukapheresis for CAR T-cell therapy in April 2019. The patient experienced significant lymphoma progression during the manufacturing process of Axicabtagene ciloleucel (Axi-cel), manifesting itself in the form of malignant pleural effusions and progressive lymphadenopathy (Fig. 2a,c,e). In the six-week period between leukapheresis and lymphodepletion, the patient remained severely neutropenic after R-CHOP and developed possible invasive fungal disease (IFD) [6] (Fig. 3e) as well as E. coli septicemia secondary to a urinary tract infection. These infections were treated successfully with liposomal amphotericin B and piperacillin/tazobactam. Prior to lymphodepletion (D-5), the patient presented with an ECOG performance status of 1, intact renal and liver function, while observing residually depressed blood counts (WBC 1270/μl, ANC 700/μl, ALC 390/μl, Hemoglobin 7.2 g/dl, Platelets 20 G/l). BM histopathology showed a hypocellular marrow with no evidence of lymphoma infiltration. Analysis of lymphocyte subpopulations demonstrated severe B-cell aplasia and decreased absolute CD4+ (84/μl) and CD8+ (271/μl) counts. His anti-infective prophylaxis consisted of a combination of acyclovir, sulfamethoxazole/trimethoprim (TMP/SMZ), and posaconazole. The fludarabine/cyclophosphamide lympho-preparative regimen was applied on days − 5 to − 3 according to the provider’s protocol, followed by CAR T-cell transfusion on day 0.
Fig. 1 Overview of CAR T-cell mediated hematotoxicity and infectious complications. a Treatment course prior to CAR T-cell therapy. b Timeline of infectious complications during CAR T-cell treatment course. Positive microbiologic culture results are underlined. Bottom: Overview of utilized anti-infectives with the respective bars displaying the length of treatment. P/T = piperacillin/tazobactam, Ami = amikacin, Mero = meropenem, Vanco = vancomycin, Line = linezolid, Posa = posaconazole (p.o.), Mica = micafungin (i.v.), Amb = liposomal amphotericin B. The patient also received prophylactic acyclovir and sulfamethoxazole/trimethoprim (TMP/SMZ) during treatment. c Complete Blood Count (CBC) timeline. ANC (blue), platelet count (green), Hemoglobin (red). Transfusion events (green: platelet transfusion, red: pRBC transfusion) and G-CSF support (blue bar) are integrated in the curve. d Dynamics of Serum Inflammatory Markers. Infectious complications are superimposed above the graph. e Histopathologic analysis of BM biopsies demonstrating severe BM aplasia 1 month after CAR T-cell transfusion (Day 32, upper panel) and evidence of recovering hematopoiesis following autologous stem cell transfer (Autopsy, lower panel). Immunohistochemical staining for myeloperoxidase (= MPO) highlighting strong activation of myelopoiesis (right panel)
Fig. 2 Radiographic evidence of partial response to Axi-cel after 36 days. Contrast-enhanced CT abdomen (axial view) displaying pleural manifestations before (a) and after (b) CAR T-cell treatment. Involved paraaortic lymph nodes (red arrows) demonstrate an interval decrease in size (c-d, e-f). The inset of panel F depicts splenic hypodensities consistent with necrosis of tumor tissue secondary to immune therapy and a reduction of splenomegaly. G Graphical depiction of response over time. Tumor extent was quantified as the sum of the product of perpendicular diameters according to Lugano criteria over 3 time points and is graphed on the y-axis. H Timeline of LDH levels (U/l). The increase in LDH levels at day 25 correlated with the gastrointestinal toxicity and liver dysfunction
Fig. 3 Multi-organ toxicity secondary to CD19-directed CAR T-cell therapy. a Contrast-enhanced CT abdomen demonstrating a non-inflamed baseline state of GI mucosal tissue prior to CAR T therapy. b Panmural swelling of the sigma (left panel), ascending colon (middle panel), and stomach. c Non-pathologic CT of the brain. d Axial FLAIR-weighted (left), T1-weighted contrast-enhanced (middle), and diffusion-weighted (right) MRI displaying no evidence of cerebral edema, white matter lesions, diffusion restriction, microbleeds, meningeal enhancement or contrast enhancing lesions. e High-resolution CT thorax with bilateral fungal infiltrates observing the typical halo configuration 6 weeks prior to CAR T-cell transfusion. f On day − 3 the right-sided infiltrates have decreased in size. The left lung is collapsed due to malignant pleural effusion. g Lung parenchyma exhibiting an infiltration of non-dimorphic blastoconidial morphology consistent with Candida glabrata. h PAS staining of a lung specimen highlights septated hiphae and acute-angle branching, features consistent of with aspergillus infection
During lymphodepletion the patient developed an upper respiratory infection, presenting with a non-productive cough and a sputum culture positive for Bordetella bronchiseptica, which resolved clinically after antibiotic treatment with piperacillin/tazobactam. On day 7, the patient developed fever with a stable cardiopulmonary function and concomitant IL-6 rise (Fig. 1d), which was classified as CRS grade I according to ASTCT consensus grading [7] in the absence of positive blood cultures and other foci. Due to persistent fever refractory to antipyretic treatment, four total doses of tocilizumab (8 mg/kg) were applied over 36 h. Starting on day 9, the patient deteriorated neurologically with a depressed state of consciousness prompting the diagnosis of grade IV ICANS. The patient was transferred to the neurological ICU, and high-dose corticosteroids (methylprednisolone 1000 mg daily) were initiated. CSF-analysis displayed subtle pleocytosis, but revealed no signs of CNS infection (viral, bacterial and fungal) or meningeal involvement of the DLBCL. CT and MR imaging of the brain exhibited none of the pathological findings reported for ICANS [8] or CNS infection [9](Fig. 3c-d). After 5 days of high-dose methylprednisolone, the patient’s neurological status slowly improved, and corticosteroids could be tapered.
Partial response to Axicabtagene-Ciloleucel after 36 days according to Lugano criteria
While the patient’s initial clinical course was fraught with complications, CT staging performed at day 36 demonstrated a partial response to CAR T-cell therapy according to Lugano and Lyric criteria (Fig. 2a-g). This was particularly evident for the pleural manifestations of the underlying DLBCL, which was accompanied by an interval decrease in pleural effusions and subjective dyspnea (Fig. 2a-b). Multiple nodal sites including paraaortic (Fig. 2c-d) and parailiac lymph nodes (Fig. 2e-f) exhibited significant regression of tumor size (Fig. 2g). Moreover, the patient displayed splenic hypodensities consistent with either tumor tissue necrosis or infection-associated inflammatory changes (inset, Fig. 2f). These CT-morphologic findings were accompanied by a decrease of LDH levels (Fig. 2h).
Prolonged cytopenia lead to the development of severe neutropenic colitis and fatal fungal pneumonia
The patient presented with significant myelotoxicity and sustained transfusion dependency after CAR T-cell administration (Fig. 1c). The overall duration of profound neutropenia – defined as an ANC < 100/μl [10] – was 52 days. Because of the severity of ICANS, the clinicians chose to hold G-CSF during this time period due to concerns for risk of worsening toxicity [11].
While receiving broad anti-infectives (acyclovir, TMP/SMZ, posaconazole, meropenem), the patient developed breakthrough septic shock on day 24. He exhibited fever (39.5 °C), hypotension (70/30 mmHg), tachycardia (160/min), as well as lactic acidosis (lactate: 10.7 mmol/l). The patient was non-conversant, non-oriented, and was not able to localize symptoms. However, he had described epigastric tenderness and subtle changes in stool consistency and frequency on the previous day. As a result, abdominal CT imaging was obtained, which displayed severe pancolitis, as evidenced by pronounced mucosal thickening with edematous changes ranging from the ascending colon to the rectum (Fig. 3a-b). Labs were notable for an acute spike of serum inflammatory parameters (Il-6 > 500.000 pg/ml, CRP 5.7 mg/dl, Procalcitonin 11.2 ng/ml, Fig. 1d). Following ICU transfer, high-dose vasopressor support with norepinephrine was initiated together with volume resuscitation to maintain organ perfusion. Due to progressive loss of consciousness the patient was intubated and mechanically ventilated. To control the proinflammatory state, extracorporeal cytokine absorption (Cytosorb®) was performed, which resulted in a decrease of soluble inflammatory markers in the subsequent days. Arterial blood cultures were positive for vancomycin-resistant enterococci (VRE), and the antibiotic treatment was escalated to include linezolid along with meropenem (Fig. 1b). The ICU team transitioned antifungal prophylaxis from posaconazole to an echinocandine (micafungin 50 mg IV) due to ECG changes and concerns for drug interactions on day 24. Though he remained in critical condition, in the coming weeks his clinical condition stabilized and both the catecholamine rate and volume support could be reduced. To determine the origin of sustained myelosuppression, a bone marrow biopsy was obtained, which depicted a hypocellular marrow and severe aplasia affecting all hematopoietic lineages (Fig. 1e). On days 41 and 49, surveillance blood cultures were positive for Candida glabrata, a commensal fungal organism of human mucosal tissues [12] harboring an intrinsic azole resistance [13]. Susceptibility testing confirmed the azole-resistance of C. glabrata isolates. The antimycotic therapy was escalated from micafungin to liposomal amphotericin B. C. glabrata likely disseminated to the bloodstream secondary to the described gastrointestinal toxicity and was previously discovered on rectal swab (Fig. 1b) and fecal culture (day − 51).
Due to sustained neutropenia, BM aplasia and the availability of a suitable apheresis product, the CAR T-cell Taskforce proceeded with a stem cell boost of previously collected autologous CD34+ cells (3,1 × 106 cells) on day 46. The combination of a sudden rise in serum inflammatory markers and a strongly positive serum galactomannan (GM) assay on day 49 prompted diagnostic bronchoscopy, which revealed a diffuse infiltrate of alveolar and peri-bronchial tissue by Aspergillus fumigatus, consistent with fulminant invasive fungal pneumonia. Over the next week, the patient became increasingly hemodynamically unstable with poor peripheral oxygenation. Repeat bronchoscopy with bronchial lavage was positive for A. fumigatus and C. glabrata. After 50 days of G-CSF refractory aplasia, the autologous stem cells slowly engrafted leading to neutrophil recovery. However, this likely exacerbated the local inflammatory reaction in the lung, contributing to rapid deterioration of his respiratory status. Despite extensive supportive measures, the patient died on day 58 after CAR T-cell transfusion. Cause of death was confirmed by autopsy as invasive fungal pneumonia with multi-organ septic spread. Post-mortem examination revealed Candida spores in intestinal, colonic and rectal tissue. Of note, histopathologic BM analysis revealed signs of burgeoning hematopoietic regeneration (Fig. 1e).
Discussion and conclusions
Recent studies have shed light on the high incidence of prolonged and profound neutropenia after adoptive immunotherapy with CD19-specific CAR T-cells [1–3]. Clinical sequalae include severe infectious complications, which have emerged as the number one cause of long-term non-relapse mortality after CAR T-cell therapy [14]. In a seminal study, Hill and colleagues demonstrate that infectious complications are common with a cumulative incidence of 23% in the first 28 days after CAR T-cell transfusion and 14% between days 29–90. While bacterial infections were most common in the first month, viral infections – especially respiratory viruses – predominated after day 29, likely as a result of an impaired adaptive immune response due to B-cell aplasia [15]. Overall, most infections were mild to moderate and fatal infections were rare. Invasive mold infections were uncommon, ranging from 1 to 7% in CAR T-cell recipients [15–17]. In multivariate analyses, the use of systemic corticosteroids for the management of CRS or ICANS has emerged as a major risk factor of infection [18]. Certain inflammatory signatures – such as the “double peaks of IL-6” pattern observed in our patient – have been shown to confer an especially high risk of life-threatening infection [19].
This case highlights the combination of factors that precipitate a high risk of infectious complications in a CAR T-cell patient. First, the heavily pre-treated patient displayed B-cell aplasia and a diminished hematopoietic reserve (e.g. trilineage cytopenia) prior to lymphodepletion. Second, the patient developed classic complications of CAR T-cell therapy such as CRS and severe and prolonged ICANS, reflecting a pro-inflammatory state that represents an important risk factor for developing infections in CAR T-cell patients [16]. The subsequent application of high-dose corticosteroids impaired both innate and adaptive immunity [20]. Third, pancytopenia was profound, prolonged and not able to be reverted by growth factor support. Fourth, the patient had a history of infectious complications, including a course of fungal pneumonia 6 weeks prior to lymphodepletion, likely flaring up in the setting of the above three factors.
Our patient developed severe septic shock secondary to neutropenic colitis on day 24, highlighting the risk of a watch-and-wait approach to prolonged neutropenia after CAR T-cell therapy. A two-pronged approach to management appears prescient. On the one hand, measures to propagate hematopoietic recovery should be exhausted (causal therapy). This can range from G-CSF stimulation, to a trial of pulse-dose corticosteroids or anti-cytokine therapy (e.g. Anakinra, Tocilizumab), to a stem cell boost as a last resort in lymphoma patients who have undergone prior autologous stem cell transplantation. On the other hand, clinicians should be at high alert for infectious complications and adapt their infection surveillance and anti-infective prophylactic strategies accordingly. For example, therapeutic drug monitoring of posaconazole and meropenem levels may have revealed subtherapeutic dosing of these anti-infective agents in this patient [21]. The role of antifungal prophylaxis in the CAR T-cell patient remains inconclusive. Adequately powered studies addressing the duration of neutropenia after CAR T-cell therapy, and potential clinical determinants of invasive fungal infections, will be critical to gauge the benefit of antifungal prophylaxis in this patient collective.
Candida species are a leading cause of fungus-associated morbidity and mortality in severely immunocompromised patients [21]. On day 41, this patient developed breakthrough C. glabrata Candidemia on micafungin, in the setting of both underlying colonization and neutropenic colitis. A recent report implicated the gastrointestinal tract as major source of echinocandin drug resistance in a murine model of C. glabrata colonization and systemic dissemination [22]. Of note, breakthrough Candida infections on micafungin may occur at the employed dose level (50 mg/day IV), suggesting that this dose may have been inadequate to prevent subsequent Candidemia [23]. Though cases of C. glabrata colitis are extremely rare [24], an opportunistic infection could not be ruled out given that C. glabrata infiltrates were discovered in enteral and colonic mucosal tissue on post-mortem examination. Importantly, the patients’ clinical status deteriorated only after the stem cell boost resulted in signs of hematopoietic recovery. The paradoxical worsening of the pulmonary A. fumigatus infection is consistent with immune reconstitution inflammatory syndrome (IRIS), which has been previously described for HIV/AIDS [25] and for severely neutropenic patients with IPA [26]. In conclusion, this case emphasizes that infectious complications secondary to prolonged cytopenia influence non-relapse mortality after CAR T-cell therapy.
Abbreviations
ALCAbsolute Lymphocyte Count
ANCAbsolute Neutrophil Count
BMBone Marrow
CARChimeric antigen receptor
CBCComplete Blood Count
CRSCytokine release syndrome
CTCAECommon Terminology Criteria for Adverse Events
DLBCLDiffuse large B-cell lymphoma
FFPFresh frozen plasma
FLAIRFluid-attenuated inversion recovery
Flu/CyFludarabine/Cyclophosphamide
G-CSFGranulocyte colony stimulating factor
GIGastrointestinal
GMGalactomannan
HSPCsHematopoietic stem and progenitor cells
ICANSImmune effector cell-associated neurotoxicity syndrome
ICE-scoreImmune Effector Cell-associated Encephalopathy score
ICUIntensive care unit
IPAInvasive pulmonary aspergillosis
LDHLactate Dehydrogenase
LYRICLymphoma response to immunomodulatory therapy criteria
MDRDModification of Diet in Renal Disease
MPOMyeloperoxidase
PASPeriodic acid-Schiff
PBSCPeripheral Blood Stem Cell
VREVancomycin-resistant Enterococcus
WBCWhite Blood Count
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Acknowledgements
Not applicable.
Authors’ contributions
The original manuscript was written by KR. KR and WGK prepared the figures. MR performed the histological examination of the bone marrow. MS reviewed and edited the manuscript. The other authors (VB1, VB2, CS, PK, FS, KD, LvB, JS, OW, MD, MvBB) contributed to patient management and participated in drafting and editing the manuscript. All authors read and approved the final manuscript.
Funding
Not applicable. Open Access funding enabled and organized by Projekt DEAL.
Availability of data and materials
The authors did not use any database, software, or tools for the writing of this manuscript.
Ethics approval and consent to participate
The authors obtained consent from the deceased patient’s next-of-kin to participate.
Consent for publication
Written informed consent was obtained from the patient’s next-of-kin for publication of this Case report and any accompanying images. A copy of the written consent is available for review by the Editor of this journal.
Competing interests
The authors declare that they have no competing interests related with this case report. | CYCLOPHOSPHAMIDE, DOXORUBICIN HYDROCHLORIDE, METHYLPREDNISOLONE, PREDNISOLONE, RITUXIMAB, VINCRISTINE | DrugsGivenReaction | CC BY | 33509115 | 18,947,434 | 2021-01-28 |
Give an alphabetized list of all active substances of drugs taken by the patient who experienced 'Septic shock'. | Severe Candida glabrata pancolitis and fatal Aspergillus fumigatus pulmonary infection in the setting of bone marrow aplasia after CD19-directed CAR T-cell therapy - a case report.
BACKGROUND
Prolonged myelosuppression following CD19-directed CAR T-cell transfusion represents an important, yet underreported, adverse event. The resulting neutropenia and multifactorial immunosuppression can facilitate severe infectious complications.
METHODS
We describe the clinical course of a 59-year-old patient with relapsed/refractory DLBCL who received Axicabtagene-Ciloleucel (Axi-cel). The patient developed ASTCT grade I CRS and grade IV ICANS, necessitating admission to the neurological ICU and prolonged application of high-dose corticosteroids and other immunosuppressive agents. Importantly, neutropenia was profound (ANC < 100/μl), G-CSF-refractory, and prolonged, lasting more than 50 days. The patient developed severe septic shock 3 weeks after CAR transfusion while receiving anti-fungal prophylaxis with micafungin. His clinical status stabilized with broad anti-infective treatment and intensive supportive measures. An autologous stem cell backup was employed on day 46 to support hematopoietic recovery. Although the counts of the patient eventually started to recover, he developed an invasive pulmonary aspergillosis, which ultimately lead to respiratory failure and death. Postmortem examination revealed signs of Candida glabrata pancolitis.
CONCLUSIONS
This case highlights the increased risk for fatal infectious complications in patients who present with profound and prolonged cytopenia after CAR T-cell therapy. We describe a rare case of C. glabrata pancolitis associated with multifactorial immunosuppression. Although our patient succumbed to a fatal fungal infection, autologous stem cell boost was able to spur hematopoiesis and may represent an important therapeutic strategy for DLBCL patients with CAR T-cell associated bone marrow aplasia who have underwent prior stem cell harvest.
Background
When CD19-directed Chimeric Antigen Receptor (CAR) T-cell therapies were first introduced into the clinical setting, a set of distinctive side effects were observed, including Cytokine Release Syndrome (CRS) and immune effector cell-associated neurotoxicity syndrome (ICANS). As these treatments transition from large clinical trials to real-world implementation, new nuances of the side effect spectrum have emerged. This includes the observation that patients can present not only with grade 3–4 cytopenia (CTCAE v5.0), but also a syndrome of persistent cytopenia after CAR T-cell transfusion [1, 2]. Hematologic toxicity is common with one study demonstrating that neutropenia, thrombocytopenia and anemia occur in 94, 80 and 51% of patients respectively [3]. Risk factors for hematotoxicity include CRS grade, baseline cytopenia, and prior allogeneic stem cell transplantation within the last year [2, 3]. The fact that baseline hematopoietic reserve contributes to cytopenia in CAR T-cell patients may explain the variability in the incidence of hematoxicity in the real-world setting compared to the large registration trials, which set stringent hematologic exclusion criteria [4, 5]. The clinical utility of therapeutic rescue strategies that mitigate the risk of infectious complications secondary to long-term bone marrow (BM) aplasia, such as early autologous stem cell boost or Eltrombopag, remains unknown. Moreover, the relative paucity of reports concerning severe and life-threatening infections in the reported CD19-directed CAR T-cell trials necessitates the presentation of distinctive clinical courses that underline the risks of persistent cytopenia after CAR T-cell therapy in a real-world setting.
Case presentation
The 59-year-old male patient was initially diagnosed with stage IIIA follicular lymphoma in January 2018, which transformed to germinal center B-cell like DLBCL in October of the same year. Refractory to multiple cycles of Rituximab-based immunochemotherapy (Fig. 1a), the patient underwent leukapheresis for CAR T-cell therapy in April 2019. The patient experienced significant lymphoma progression during the manufacturing process of Axicabtagene ciloleucel (Axi-cel), manifesting itself in the form of malignant pleural effusions and progressive lymphadenopathy (Fig. 2a,c,e). In the six-week period between leukapheresis and lymphodepletion, the patient remained severely neutropenic after R-CHOP and developed possible invasive fungal disease (IFD) [6] (Fig. 3e) as well as E. coli septicemia secondary to a urinary tract infection. These infections were treated successfully with liposomal amphotericin B and piperacillin/tazobactam. Prior to lymphodepletion (D-5), the patient presented with an ECOG performance status of 1, intact renal and liver function, while observing residually depressed blood counts (WBC 1270/μl, ANC 700/μl, ALC 390/μl, Hemoglobin 7.2 g/dl, Platelets 20 G/l). BM histopathology showed a hypocellular marrow with no evidence of lymphoma infiltration. Analysis of lymphocyte subpopulations demonstrated severe B-cell aplasia and decreased absolute CD4+ (84/μl) and CD8+ (271/μl) counts. His anti-infective prophylaxis consisted of a combination of acyclovir, sulfamethoxazole/trimethoprim (TMP/SMZ), and posaconazole. The fludarabine/cyclophosphamide lympho-preparative regimen was applied on days − 5 to − 3 according to the provider’s protocol, followed by CAR T-cell transfusion on day 0.
Fig. 1 Overview of CAR T-cell mediated hematotoxicity and infectious complications. a Treatment course prior to CAR T-cell therapy. b Timeline of infectious complications during CAR T-cell treatment course. Positive microbiologic culture results are underlined. Bottom: Overview of utilized anti-infectives with the respective bars displaying the length of treatment. P/T = piperacillin/tazobactam, Ami = amikacin, Mero = meropenem, Vanco = vancomycin, Line = linezolid, Posa = posaconazole (p.o.), Mica = micafungin (i.v.), Amb = liposomal amphotericin B. The patient also received prophylactic acyclovir and sulfamethoxazole/trimethoprim (TMP/SMZ) during treatment. c Complete Blood Count (CBC) timeline. ANC (blue), platelet count (green), Hemoglobin (red). Transfusion events (green: platelet transfusion, red: pRBC transfusion) and G-CSF support (blue bar) are integrated in the curve. d Dynamics of Serum Inflammatory Markers. Infectious complications are superimposed above the graph. e Histopathologic analysis of BM biopsies demonstrating severe BM aplasia 1 month after CAR T-cell transfusion (Day 32, upper panel) and evidence of recovering hematopoiesis following autologous stem cell transfer (Autopsy, lower panel). Immunohistochemical staining for myeloperoxidase (= MPO) highlighting strong activation of myelopoiesis (right panel)
Fig. 2 Radiographic evidence of partial response to Axi-cel after 36 days. Contrast-enhanced CT abdomen (axial view) displaying pleural manifestations before (a) and after (b) CAR T-cell treatment. Involved paraaortic lymph nodes (red arrows) demonstrate an interval decrease in size (c-d, e-f). The inset of panel F depicts splenic hypodensities consistent with necrosis of tumor tissue secondary to immune therapy and a reduction of splenomegaly. G Graphical depiction of response over time. Tumor extent was quantified as the sum of the product of perpendicular diameters according to Lugano criteria over 3 time points and is graphed on the y-axis. H Timeline of LDH levels (U/l). The increase in LDH levels at day 25 correlated with the gastrointestinal toxicity and liver dysfunction
Fig. 3 Multi-organ toxicity secondary to CD19-directed CAR T-cell therapy. a Contrast-enhanced CT abdomen demonstrating a non-inflamed baseline state of GI mucosal tissue prior to CAR T therapy. b Panmural swelling of the sigma (left panel), ascending colon (middle panel), and stomach. c Non-pathologic CT of the brain. d Axial FLAIR-weighted (left), T1-weighted contrast-enhanced (middle), and diffusion-weighted (right) MRI displaying no evidence of cerebral edema, white matter lesions, diffusion restriction, microbleeds, meningeal enhancement or contrast enhancing lesions. e High-resolution CT thorax with bilateral fungal infiltrates observing the typical halo configuration 6 weeks prior to CAR T-cell transfusion. f On day − 3 the right-sided infiltrates have decreased in size. The left lung is collapsed due to malignant pleural effusion. g Lung parenchyma exhibiting an infiltration of non-dimorphic blastoconidial morphology consistent with Candida glabrata. h PAS staining of a lung specimen highlights septated hiphae and acute-angle branching, features consistent of with aspergillus infection
During lymphodepletion the patient developed an upper respiratory infection, presenting with a non-productive cough and a sputum culture positive for Bordetella bronchiseptica, which resolved clinically after antibiotic treatment with piperacillin/tazobactam. On day 7, the patient developed fever with a stable cardiopulmonary function and concomitant IL-6 rise (Fig. 1d), which was classified as CRS grade I according to ASTCT consensus grading [7] in the absence of positive blood cultures and other foci. Due to persistent fever refractory to antipyretic treatment, four total doses of tocilizumab (8 mg/kg) were applied over 36 h. Starting on day 9, the patient deteriorated neurologically with a depressed state of consciousness prompting the diagnosis of grade IV ICANS. The patient was transferred to the neurological ICU, and high-dose corticosteroids (methylprednisolone 1000 mg daily) were initiated. CSF-analysis displayed subtle pleocytosis, but revealed no signs of CNS infection (viral, bacterial and fungal) or meningeal involvement of the DLBCL. CT and MR imaging of the brain exhibited none of the pathological findings reported for ICANS [8] or CNS infection [9](Fig. 3c-d). After 5 days of high-dose methylprednisolone, the patient’s neurological status slowly improved, and corticosteroids could be tapered.
Partial response to Axicabtagene-Ciloleucel after 36 days according to Lugano criteria
While the patient’s initial clinical course was fraught with complications, CT staging performed at day 36 demonstrated a partial response to CAR T-cell therapy according to Lugano and Lyric criteria (Fig. 2a-g). This was particularly evident for the pleural manifestations of the underlying DLBCL, which was accompanied by an interval decrease in pleural effusions and subjective dyspnea (Fig. 2a-b). Multiple nodal sites including paraaortic (Fig. 2c-d) and parailiac lymph nodes (Fig. 2e-f) exhibited significant regression of tumor size (Fig. 2g). Moreover, the patient displayed splenic hypodensities consistent with either tumor tissue necrosis or infection-associated inflammatory changes (inset, Fig. 2f). These CT-morphologic findings were accompanied by a decrease of LDH levels (Fig. 2h).
Prolonged cytopenia lead to the development of severe neutropenic colitis and fatal fungal pneumonia
The patient presented with significant myelotoxicity and sustained transfusion dependency after CAR T-cell administration (Fig. 1c). The overall duration of profound neutropenia – defined as an ANC < 100/μl [10] – was 52 days. Because of the severity of ICANS, the clinicians chose to hold G-CSF during this time period due to concerns for risk of worsening toxicity [11].
While receiving broad anti-infectives (acyclovir, TMP/SMZ, posaconazole, meropenem), the patient developed breakthrough septic shock on day 24. He exhibited fever (39.5 °C), hypotension (70/30 mmHg), tachycardia (160/min), as well as lactic acidosis (lactate: 10.7 mmol/l). The patient was non-conversant, non-oriented, and was not able to localize symptoms. However, he had described epigastric tenderness and subtle changes in stool consistency and frequency on the previous day. As a result, abdominal CT imaging was obtained, which displayed severe pancolitis, as evidenced by pronounced mucosal thickening with edematous changes ranging from the ascending colon to the rectum (Fig. 3a-b). Labs were notable for an acute spike of serum inflammatory parameters (Il-6 > 500.000 pg/ml, CRP 5.7 mg/dl, Procalcitonin 11.2 ng/ml, Fig. 1d). Following ICU transfer, high-dose vasopressor support with norepinephrine was initiated together with volume resuscitation to maintain organ perfusion. Due to progressive loss of consciousness the patient was intubated and mechanically ventilated. To control the proinflammatory state, extracorporeal cytokine absorption (Cytosorb®) was performed, which resulted in a decrease of soluble inflammatory markers in the subsequent days. Arterial blood cultures were positive for vancomycin-resistant enterococci (VRE), and the antibiotic treatment was escalated to include linezolid along with meropenem (Fig. 1b). The ICU team transitioned antifungal prophylaxis from posaconazole to an echinocandine (micafungin 50 mg IV) due to ECG changes and concerns for drug interactions on day 24. Though he remained in critical condition, in the coming weeks his clinical condition stabilized and both the catecholamine rate and volume support could be reduced. To determine the origin of sustained myelosuppression, a bone marrow biopsy was obtained, which depicted a hypocellular marrow and severe aplasia affecting all hematopoietic lineages (Fig. 1e). On days 41 and 49, surveillance blood cultures were positive for Candida glabrata, a commensal fungal organism of human mucosal tissues [12] harboring an intrinsic azole resistance [13]. Susceptibility testing confirmed the azole-resistance of C. glabrata isolates. The antimycotic therapy was escalated from micafungin to liposomal amphotericin B. C. glabrata likely disseminated to the bloodstream secondary to the described gastrointestinal toxicity and was previously discovered on rectal swab (Fig. 1b) and fecal culture (day − 51).
Due to sustained neutropenia, BM aplasia and the availability of a suitable apheresis product, the CAR T-cell Taskforce proceeded with a stem cell boost of previously collected autologous CD34+ cells (3,1 × 106 cells) on day 46. The combination of a sudden rise in serum inflammatory markers and a strongly positive serum galactomannan (GM) assay on day 49 prompted diagnostic bronchoscopy, which revealed a diffuse infiltrate of alveolar and peri-bronchial tissue by Aspergillus fumigatus, consistent with fulminant invasive fungal pneumonia. Over the next week, the patient became increasingly hemodynamically unstable with poor peripheral oxygenation. Repeat bronchoscopy with bronchial lavage was positive for A. fumigatus and C. glabrata. After 50 days of G-CSF refractory aplasia, the autologous stem cells slowly engrafted leading to neutrophil recovery. However, this likely exacerbated the local inflammatory reaction in the lung, contributing to rapid deterioration of his respiratory status. Despite extensive supportive measures, the patient died on day 58 after CAR T-cell transfusion. Cause of death was confirmed by autopsy as invasive fungal pneumonia with multi-organ septic spread. Post-mortem examination revealed Candida spores in intestinal, colonic and rectal tissue. Of note, histopathologic BM analysis revealed signs of burgeoning hematopoietic regeneration (Fig. 1e).
Discussion and conclusions
Recent studies have shed light on the high incidence of prolonged and profound neutropenia after adoptive immunotherapy with CD19-specific CAR T-cells [1–3]. Clinical sequalae include severe infectious complications, which have emerged as the number one cause of long-term non-relapse mortality after CAR T-cell therapy [14]. In a seminal study, Hill and colleagues demonstrate that infectious complications are common with a cumulative incidence of 23% in the first 28 days after CAR T-cell transfusion and 14% between days 29–90. While bacterial infections were most common in the first month, viral infections – especially respiratory viruses – predominated after day 29, likely as a result of an impaired adaptive immune response due to B-cell aplasia [15]. Overall, most infections were mild to moderate and fatal infections were rare. Invasive mold infections were uncommon, ranging from 1 to 7% in CAR T-cell recipients [15–17]. In multivariate analyses, the use of systemic corticosteroids for the management of CRS or ICANS has emerged as a major risk factor of infection [18]. Certain inflammatory signatures – such as the “double peaks of IL-6” pattern observed in our patient – have been shown to confer an especially high risk of life-threatening infection [19].
This case highlights the combination of factors that precipitate a high risk of infectious complications in a CAR T-cell patient. First, the heavily pre-treated patient displayed B-cell aplasia and a diminished hematopoietic reserve (e.g. trilineage cytopenia) prior to lymphodepletion. Second, the patient developed classic complications of CAR T-cell therapy such as CRS and severe and prolonged ICANS, reflecting a pro-inflammatory state that represents an important risk factor for developing infections in CAR T-cell patients [16]. The subsequent application of high-dose corticosteroids impaired both innate and adaptive immunity [20]. Third, pancytopenia was profound, prolonged and not able to be reverted by growth factor support. Fourth, the patient had a history of infectious complications, including a course of fungal pneumonia 6 weeks prior to lymphodepletion, likely flaring up in the setting of the above three factors.
Our patient developed severe septic shock secondary to neutropenic colitis on day 24, highlighting the risk of a watch-and-wait approach to prolonged neutropenia after CAR T-cell therapy. A two-pronged approach to management appears prescient. On the one hand, measures to propagate hematopoietic recovery should be exhausted (causal therapy). This can range from G-CSF stimulation, to a trial of pulse-dose corticosteroids or anti-cytokine therapy (e.g. Anakinra, Tocilizumab), to a stem cell boost as a last resort in lymphoma patients who have undergone prior autologous stem cell transplantation. On the other hand, clinicians should be at high alert for infectious complications and adapt their infection surveillance and anti-infective prophylactic strategies accordingly. For example, therapeutic drug monitoring of posaconazole and meropenem levels may have revealed subtherapeutic dosing of these anti-infective agents in this patient [21]. The role of antifungal prophylaxis in the CAR T-cell patient remains inconclusive. Adequately powered studies addressing the duration of neutropenia after CAR T-cell therapy, and potential clinical determinants of invasive fungal infections, will be critical to gauge the benefit of antifungal prophylaxis in this patient collective.
Candida species are a leading cause of fungus-associated morbidity and mortality in severely immunocompromised patients [21]. On day 41, this patient developed breakthrough C. glabrata Candidemia on micafungin, in the setting of both underlying colonization and neutropenic colitis. A recent report implicated the gastrointestinal tract as major source of echinocandin drug resistance in a murine model of C. glabrata colonization and systemic dissemination [22]. Of note, breakthrough Candida infections on micafungin may occur at the employed dose level (50 mg/day IV), suggesting that this dose may have been inadequate to prevent subsequent Candidemia [23]. Though cases of C. glabrata colitis are extremely rare [24], an opportunistic infection could not be ruled out given that C. glabrata infiltrates were discovered in enteral and colonic mucosal tissue on post-mortem examination. Importantly, the patients’ clinical status deteriorated only after the stem cell boost resulted in signs of hematopoietic recovery. The paradoxical worsening of the pulmonary A. fumigatus infection is consistent with immune reconstitution inflammatory syndrome (IRIS), which has been previously described for HIV/AIDS [25] and for severely neutropenic patients with IPA [26]. In conclusion, this case emphasizes that infectious complications secondary to prolonged cytopenia influence non-relapse mortality after CAR T-cell therapy.
Abbreviations
ALCAbsolute Lymphocyte Count
ANCAbsolute Neutrophil Count
BMBone Marrow
CARChimeric antigen receptor
CBCComplete Blood Count
CRSCytokine release syndrome
CTCAECommon Terminology Criteria for Adverse Events
DLBCLDiffuse large B-cell lymphoma
FFPFresh frozen plasma
FLAIRFluid-attenuated inversion recovery
Flu/CyFludarabine/Cyclophosphamide
G-CSFGranulocyte colony stimulating factor
GIGastrointestinal
GMGalactomannan
HSPCsHematopoietic stem and progenitor cells
ICANSImmune effector cell-associated neurotoxicity syndrome
ICE-scoreImmune Effector Cell-associated Encephalopathy score
ICUIntensive care unit
IPAInvasive pulmonary aspergillosis
LDHLactate Dehydrogenase
LYRICLymphoma response to immunomodulatory therapy criteria
MDRDModification of Diet in Renal Disease
MPOMyeloperoxidase
PASPeriodic acid-Schiff
PBSCPeripheral Blood Stem Cell
VREVancomycin-resistant Enterococcus
WBCWhite Blood Count
Publisher’s Note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
Acknowledgements
Not applicable.
Authors’ contributions
The original manuscript was written by KR. KR and WGK prepared the figures. MR performed the histological examination of the bone marrow. MS reviewed and edited the manuscript. The other authors (VB1, VB2, CS, PK, FS, KD, LvB, JS, OW, MD, MvBB) contributed to patient management and participated in drafting and editing the manuscript. All authors read and approved the final manuscript.
Funding
Not applicable. Open Access funding enabled and organized by Projekt DEAL.
Availability of data and materials
The authors did not use any database, software, or tools for the writing of this manuscript.
Ethics approval and consent to participate
The authors obtained consent from the deceased patient’s next-of-kin to participate.
Consent for publication
Written informed consent was obtained from the patient’s next-of-kin for publication of this Case report and any accompanying images. A copy of the written consent is available for review by the Editor of this journal.
Competing interests
The authors declare that they have no competing interests related with this case report. | CYCLOPHOSPHAMIDE, DOXORUBICIN HYDROCHLORIDE, METHYLPREDNISOLONE, PREDNISOLONE, RITUXIMAB, VINCRISTINE | DrugsGivenReaction | CC BY | 33509115 | 18,947,434 | 2021-01-28 |
Give an alphabetized list of all active substances of drugs taken by the patient who experienced 'Urinary tract infection'. | Severe Candida glabrata pancolitis and fatal Aspergillus fumigatus pulmonary infection in the setting of bone marrow aplasia after CD19-directed CAR T-cell therapy - a case report.
BACKGROUND
Prolonged myelosuppression following CD19-directed CAR T-cell transfusion represents an important, yet underreported, adverse event. The resulting neutropenia and multifactorial immunosuppression can facilitate severe infectious complications.
METHODS
We describe the clinical course of a 59-year-old patient with relapsed/refractory DLBCL who received Axicabtagene-Ciloleucel (Axi-cel). The patient developed ASTCT grade I CRS and grade IV ICANS, necessitating admission to the neurological ICU and prolonged application of high-dose corticosteroids and other immunosuppressive agents. Importantly, neutropenia was profound (ANC < 100/μl), G-CSF-refractory, and prolonged, lasting more than 50 days. The patient developed severe septic shock 3 weeks after CAR transfusion while receiving anti-fungal prophylaxis with micafungin. His clinical status stabilized with broad anti-infective treatment and intensive supportive measures. An autologous stem cell backup was employed on day 46 to support hematopoietic recovery. Although the counts of the patient eventually started to recover, he developed an invasive pulmonary aspergillosis, which ultimately lead to respiratory failure and death. Postmortem examination revealed signs of Candida glabrata pancolitis.
CONCLUSIONS
This case highlights the increased risk for fatal infectious complications in patients who present with profound and prolonged cytopenia after CAR T-cell therapy. We describe a rare case of C. glabrata pancolitis associated with multifactorial immunosuppression. Although our patient succumbed to a fatal fungal infection, autologous stem cell boost was able to spur hematopoiesis and may represent an important therapeutic strategy for DLBCL patients with CAR T-cell associated bone marrow aplasia who have underwent prior stem cell harvest.
Background
When CD19-directed Chimeric Antigen Receptor (CAR) T-cell therapies were first introduced into the clinical setting, a set of distinctive side effects were observed, including Cytokine Release Syndrome (CRS) and immune effector cell-associated neurotoxicity syndrome (ICANS). As these treatments transition from large clinical trials to real-world implementation, new nuances of the side effect spectrum have emerged. This includes the observation that patients can present not only with grade 3–4 cytopenia (CTCAE v5.0), but also a syndrome of persistent cytopenia after CAR T-cell transfusion [1, 2]. Hematologic toxicity is common with one study demonstrating that neutropenia, thrombocytopenia and anemia occur in 94, 80 and 51% of patients respectively [3]. Risk factors for hematotoxicity include CRS grade, baseline cytopenia, and prior allogeneic stem cell transplantation within the last year [2, 3]. The fact that baseline hematopoietic reserve contributes to cytopenia in CAR T-cell patients may explain the variability in the incidence of hematoxicity in the real-world setting compared to the large registration trials, which set stringent hematologic exclusion criteria [4, 5]. The clinical utility of therapeutic rescue strategies that mitigate the risk of infectious complications secondary to long-term bone marrow (BM) aplasia, such as early autologous stem cell boost or Eltrombopag, remains unknown. Moreover, the relative paucity of reports concerning severe and life-threatening infections in the reported CD19-directed CAR T-cell trials necessitates the presentation of distinctive clinical courses that underline the risks of persistent cytopenia after CAR T-cell therapy in a real-world setting.
Case presentation
The 59-year-old male patient was initially diagnosed with stage IIIA follicular lymphoma in January 2018, which transformed to germinal center B-cell like DLBCL in October of the same year. Refractory to multiple cycles of Rituximab-based immunochemotherapy (Fig. 1a), the patient underwent leukapheresis for CAR T-cell therapy in April 2019. The patient experienced significant lymphoma progression during the manufacturing process of Axicabtagene ciloleucel (Axi-cel), manifesting itself in the form of malignant pleural effusions and progressive lymphadenopathy (Fig. 2a,c,e). In the six-week period between leukapheresis and lymphodepletion, the patient remained severely neutropenic after R-CHOP and developed possible invasive fungal disease (IFD) [6] (Fig. 3e) as well as E. coli septicemia secondary to a urinary tract infection. These infections were treated successfully with liposomal amphotericin B and piperacillin/tazobactam. Prior to lymphodepletion (D-5), the patient presented with an ECOG performance status of 1, intact renal and liver function, while observing residually depressed blood counts (WBC 1270/μl, ANC 700/μl, ALC 390/μl, Hemoglobin 7.2 g/dl, Platelets 20 G/l). BM histopathology showed a hypocellular marrow with no evidence of lymphoma infiltration. Analysis of lymphocyte subpopulations demonstrated severe B-cell aplasia and decreased absolute CD4+ (84/μl) and CD8+ (271/μl) counts. His anti-infective prophylaxis consisted of a combination of acyclovir, sulfamethoxazole/trimethoprim (TMP/SMZ), and posaconazole. The fludarabine/cyclophosphamide lympho-preparative regimen was applied on days − 5 to − 3 according to the provider’s protocol, followed by CAR T-cell transfusion on day 0.
Fig. 1 Overview of CAR T-cell mediated hematotoxicity and infectious complications. a Treatment course prior to CAR T-cell therapy. b Timeline of infectious complications during CAR T-cell treatment course. Positive microbiologic culture results are underlined. Bottom: Overview of utilized anti-infectives with the respective bars displaying the length of treatment. P/T = piperacillin/tazobactam, Ami = amikacin, Mero = meropenem, Vanco = vancomycin, Line = linezolid, Posa = posaconazole (p.o.), Mica = micafungin (i.v.), Amb = liposomal amphotericin B. The patient also received prophylactic acyclovir and sulfamethoxazole/trimethoprim (TMP/SMZ) during treatment. c Complete Blood Count (CBC) timeline. ANC (blue), platelet count (green), Hemoglobin (red). Transfusion events (green: platelet transfusion, red: pRBC transfusion) and G-CSF support (blue bar) are integrated in the curve. d Dynamics of Serum Inflammatory Markers. Infectious complications are superimposed above the graph. e Histopathologic analysis of BM biopsies demonstrating severe BM aplasia 1 month after CAR T-cell transfusion (Day 32, upper panel) and evidence of recovering hematopoiesis following autologous stem cell transfer (Autopsy, lower panel). Immunohistochemical staining for myeloperoxidase (= MPO) highlighting strong activation of myelopoiesis (right panel)
Fig. 2 Radiographic evidence of partial response to Axi-cel after 36 days. Contrast-enhanced CT abdomen (axial view) displaying pleural manifestations before (a) and after (b) CAR T-cell treatment. Involved paraaortic lymph nodes (red arrows) demonstrate an interval decrease in size (c-d, e-f). The inset of panel F depicts splenic hypodensities consistent with necrosis of tumor tissue secondary to immune therapy and a reduction of splenomegaly. G Graphical depiction of response over time. Tumor extent was quantified as the sum of the product of perpendicular diameters according to Lugano criteria over 3 time points and is graphed on the y-axis. H Timeline of LDH levels (U/l). The increase in LDH levels at day 25 correlated with the gastrointestinal toxicity and liver dysfunction
Fig. 3 Multi-organ toxicity secondary to CD19-directed CAR T-cell therapy. a Contrast-enhanced CT abdomen demonstrating a non-inflamed baseline state of GI mucosal tissue prior to CAR T therapy. b Panmural swelling of the sigma (left panel), ascending colon (middle panel), and stomach. c Non-pathologic CT of the brain. d Axial FLAIR-weighted (left), T1-weighted contrast-enhanced (middle), and diffusion-weighted (right) MRI displaying no evidence of cerebral edema, white matter lesions, diffusion restriction, microbleeds, meningeal enhancement or contrast enhancing lesions. e High-resolution CT thorax with bilateral fungal infiltrates observing the typical halo configuration 6 weeks prior to CAR T-cell transfusion. f On day − 3 the right-sided infiltrates have decreased in size. The left lung is collapsed due to malignant pleural effusion. g Lung parenchyma exhibiting an infiltration of non-dimorphic blastoconidial morphology consistent with Candida glabrata. h PAS staining of a lung specimen highlights septated hiphae and acute-angle branching, features consistent of with aspergillus infection
During lymphodepletion the patient developed an upper respiratory infection, presenting with a non-productive cough and a sputum culture positive for Bordetella bronchiseptica, which resolved clinically after antibiotic treatment with piperacillin/tazobactam. On day 7, the patient developed fever with a stable cardiopulmonary function and concomitant IL-6 rise (Fig. 1d), which was classified as CRS grade I according to ASTCT consensus grading [7] in the absence of positive blood cultures and other foci. Due to persistent fever refractory to antipyretic treatment, four total doses of tocilizumab (8 mg/kg) were applied over 36 h. Starting on day 9, the patient deteriorated neurologically with a depressed state of consciousness prompting the diagnosis of grade IV ICANS. The patient was transferred to the neurological ICU, and high-dose corticosteroids (methylprednisolone 1000 mg daily) were initiated. CSF-analysis displayed subtle pleocytosis, but revealed no signs of CNS infection (viral, bacterial and fungal) or meningeal involvement of the DLBCL. CT and MR imaging of the brain exhibited none of the pathological findings reported for ICANS [8] or CNS infection [9](Fig. 3c-d). After 5 days of high-dose methylprednisolone, the patient’s neurological status slowly improved, and corticosteroids could be tapered.
Partial response to Axicabtagene-Ciloleucel after 36 days according to Lugano criteria
While the patient’s initial clinical course was fraught with complications, CT staging performed at day 36 demonstrated a partial response to CAR T-cell therapy according to Lugano and Lyric criteria (Fig. 2a-g). This was particularly evident for the pleural manifestations of the underlying DLBCL, which was accompanied by an interval decrease in pleural effusions and subjective dyspnea (Fig. 2a-b). Multiple nodal sites including paraaortic (Fig. 2c-d) and parailiac lymph nodes (Fig. 2e-f) exhibited significant regression of tumor size (Fig. 2g). Moreover, the patient displayed splenic hypodensities consistent with either tumor tissue necrosis or infection-associated inflammatory changes (inset, Fig. 2f). These CT-morphologic findings were accompanied by a decrease of LDH levels (Fig. 2h).
Prolonged cytopenia lead to the development of severe neutropenic colitis and fatal fungal pneumonia
The patient presented with significant myelotoxicity and sustained transfusion dependency after CAR T-cell administration (Fig. 1c). The overall duration of profound neutropenia – defined as an ANC < 100/μl [10] – was 52 days. Because of the severity of ICANS, the clinicians chose to hold G-CSF during this time period due to concerns for risk of worsening toxicity [11].
While receiving broad anti-infectives (acyclovir, TMP/SMZ, posaconazole, meropenem), the patient developed breakthrough septic shock on day 24. He exhibited fever (39.5 °C), hypotension (70/30 mmHg), tachycardia (160/min), as well as lactic acidosis (lactate: 10.7 mmol/l). The patient was non-conversant, non-oriented, and was not able to localize symptoms. However, he had described epigastric tenderness and subtle changes in stool consistency and frequency on the previous day. As a result, abdominal CT imaging was obtained, which displayed severe pancolitis, as evidenced by pronounced mucosal thickening with edematous changes ranging from the ascending colon to the rectum (Fig. 3a-b). Labs were notable for an acute spike of serum inflammatory parameters (Il-6 > 500.000 pg/ml, CRP 5.7 mg/dl, Procalcitonin 11.2 ng/ml, Fig. 1d). Following ICU transfer, high-dose vasopressor support with norepinephrine was initiated together with volume resuscitation to maintain organ perfusion. Due to progressive loss of consciousness the patient was intubated and mechanically ventilated. To control the proinflammatory state, extracorporeal cytokine absorption (Cytosorb®) was performed, which resulted in a decrease of soluble inflammatory markers in the subsequent days. Arterial blood cultures were positive for vancomycin-resistant enterococci (VRE), and the antibiotic treatment was escalated to include linezolid along with meropenem (Fig. 1b). The ICU team transitioned antifungal prophylaxis from posaconazole to an echinocandine (micafungin 50 mg IV) due to ECG changes and concerns for drug interactions on day 24. Though he remained in critical condition, in the coming weeks his clinical condition stabilized and both the catecholamine rate and volume support could be reduced. To determine the origin of sustained myelosuppression, a bone marrow biopsy was obtained, which depicted a hypocellular marrow and severe aplasia affecting all hematopoietic lineages (Fig. 1e). On days 41 and 49, surveillance blood cultures were positive for Candida glabrata, a commensal fungal organism of human mucosal tissues [12] harboring an intrinsic azole resistance [13]. Susceptibility testing confirmed the azole-resistance of C. glabrata isolates. The antimycotic therapy was escalated from micafungin to liposomal amphotericin B. C. glabrata likely disseminated to the bloodstream secondary to the described gastrointestinal toxicity and was previously discovered on rectal swab (Fig. 1b) and fecal culture (day − 51).
Due to sustained neutropenia, BM aplasia and the availability of a suitable apheresis product, the CAR T-cell Taskforce proceeded with a stem cell boost of previously collected autologous CD34+ cells (3,1 × 106 cells) on day 46. The combination of a sudden rise in serum inflammatory markers and a strongly positive serum galactomannan (GM) assay on day 49 prompted diagnostic bronchoscopy, which revealed a diffuse infiltrate of alveolar and peri-bronchial tissue by Aspergillus fumigatus, consistent with fulminant invasive fungal pneumonia. Over the next week, the patient became increasingly hemodynamically unstable with poor peripheral oxygenation. Repeat bronchoscopy with bronchial lavage was positive for A. fumigatus and C. glabrata. After 50 days of G-CSF refractory aplasia, the autologous stem cells slowly engrafted leading to neutrophil recovery. However, this likely exacerbated the local inflammatory reaction in the lung, contributing to rapid deterioration of his respiratory status. Despite extensive supportive measures, the patient died on day 58 after CAR T-cell transfusion. Cause of death was confirmed by autopsy as invasive fungal pneumonia with multi-organ septic spread. Post-mortem examination revealed Candida spores in intestinal, colonic and rectal tissue. Of note, histopathologic BM analysis revealed signs of burgeoning hematopoietic regeneration (Fig. 1e).
Discussion and conclusions
Recent studies have shed light on the high incidence of prolonged and profound neutropenia after adoptive immunotherapy with CD19-specific CAR T-cells [1–3]. Clinical sequalae include severe infectious complications, which have emerged as the number one cause of long-term non-relapse mortality after CAR T-cell therapy [14]. In a seminal study, Hill and colleagues demonstrate that infectious complications are common with a cumulative incidence of 23% in the first 28 days after CAR T-cell transfusion and 14% between days 29–90. While bacterial infections were most common in the first month, viral infections – especially respiratory viruses – predominated after day 29, likely as a result of an impaired adaptive immune response due to B-cell aplasia [15]. Overall, most infections were mild to moderate and fatal infections were rare. Invasive mold infections were uncommon, ranging from 1 to 7% in CAR T-cell recipients [15–17]. In multivariate analyses, the use of systemic corticosteroids for the management of CRS or ICANS has emerged as a major risk factor of infection [18]. Certain inflammatory signatures – such as the “double peaks of IL-6” pattern observed in our patient – have been shown to confer an especially high risk of life-threatening infection [19].
This case highlights the combination of factors that precipitate a high risk of infectious complications in a CAR T-cell patient. First, the heavily pre-treated patient displayed B-cell aplasia and a diminished hematopoietic reserve (e.g. trilineage cytopenia) prior to lymphodepletion. Second, the patient developed classic complications of CAR T-cell therapy such as CRS and severe and prolonged ICANS, reflecting a pro-inflammatory state that represents an important risk factor for developing infections in CAR T-cell patients [16]. The subsequent application of high-dose corticosteroids impaired both innate and adaptive immunity [20]. Third, pancytopenia was profound, prolonged and not able to be reverted by growth factor support. Fourth, the patient had a history of infectious complications, including a course of fungal pneumonia 6 weeks prior to lymphodepletion, likely flaring up in the setting of the above three factors.
Our patient developed severe septic shock secondary to neutropenic colitis on day 24, highlighting the risk of a watch-and-wait approach to prolonged neutropenia after CAR T-cell therapy. A two-pronged approach to management appears prescient. On the one hand, measures to propagate hematopoietic recovery should be exhausted (causal therapy). This can range from G-CSF stimulation, to a trial of pulse-dose corticosteroids or anti-cytokine therapy (e.g. Anakinra, Tocilizumab), to a stem cell boost as a last resort in lymphoma patients who have undergone prior autologous stem cell transplantation. On the other hand, clinicians should be at high alert for infectious complications and adapt their infection surveillance and anti-infective prophylactic strategies accordingly. For example, therapeutic drug monitoring of posaconazole and meropenem levels may have revealed subtherapeutic dosing of these anti-infective agents in this patient [21]. The role of antifungal prophylaxis in the CAR T-cell patient remains inconclusive. Adequately powered studies addressing the duration of neutropenia after CAR T-cell therapy, and potential clinical determinants of invasive fungal infections, will be critical to gauge the benefit of antifungal prophylaxis in this patient collective.
Candida species are a leading cause of fungus-associated morbidity and mortality in severely immunocompromised patients [21]. On day 41, this patient developed breakthrough C. glabrata Candidemia on micafungin, in the setting of both underlying colonization and neutropenic colitis. A recent report implicated the gastrointestinal tract as major source of echinocandin drug resistance in a murine model of C. glabrata colonization and systemic dissemination [22]. Of note, breakthrough Candida infections on micafungin may occur at the employed dose level (50 mg/day IV), suggesting that this dose may have been inadequate to prevent subsequent Candidemia [23]. Though cases of C. glabrata colitis are extremely rare [24], an opportunistic infection could not be ruled out given that C. glabrata infiltrates were discovered in enteral and colonic mucosal tissue on post-mortem examination. Importantly, the patients’ clinical status deteriorated only after the stem cell boost resulted in signs of hematopoietic recovery. The paradoxical worsening of the pulmonary A. fumigatus infection is consistent with immune reconstitution inflammatory syndrome (IRIS), which has been previously described for HIV/AIDS [25] and for severely neutropenic patients with IPA [26]. In conclusion, this case emphasizes that infectious complications secondary to prolonged cytopenia influence non-relapse mortality after CAR T-cell therapy.
Abbreviations
ALCAbsolute Lymphocyte Count
ANCAbsolute Neutrophil Count
BMBone Marrow
CARChimeric antigen receptor
CBCComplete Blood Count
CRSCytokine release syndrome
CTCAECommon Terminology Criteria for Adverse Events
DLBCLDiffuse large B-cell lymphoma
FFPFresh frozen plasma
FLAIRFluid-attenuated inversion recovery
Flu/CyFludarabine/Cyclophosphamide
G-CSFGranulocyte colony stimulating factor
GIGastrointestinal
GMGalactomannan
HSPCsHematopoietic stem and progenitor cells
ICANSImmune effector cell-associated neurotoxicity syndrome
ICE-scoreImmune Effector Cell-associated Encephalopathy score
ICUIntensive care unit
IPAInvasive pulmonary aspergillosis
LDHLactate Dehydrogenase
LYRICLymphoma response to immunomodulatory therapy criteria
MDRDModification of Diet in Renal Disease
MPOMyeloperoxidase
PASPeriodic acid-Schiff
PBSCPeripheral Blood Stem Cell
VREVancomycin-resistant Enterococcus
WBCWhite Blood Count
Publisher’s Note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
Acknowledgements
Not applicable.
Authors’ contributions
The original manuscript was written by KR. KR and WGK prepared the figures. MR performed the histological examination of the bone marrow. MS reviewed and edited the manuscript. The other authors (VB1, VB2, CS, PK, FS, KD, LvB, JS, OW, MD, MvBB) contributed to patient management and participated in drafting and editing the manuscript. All authors read and approved the final manuscript.
Funding
Not applicable. Open Access funding enabled and organized by Projekt DEAL.
Availability of data and materials
The authors did not use any database, software, or tools for the writing of this manuscript.
Ethics approval and consent to participate
The authors obtained consent from the deceased patient’s next-of-kin to participate.
Consent for publication
Written informed consent was obtained from the patient’s next-of-kin for publication of this Case report and any accompanying images. A copy of the written consent is available for review by the Editor of this journal.
Competing interests
The authors declare that they have no competing interests related with this case report. | CYCLOPHOSPHAMIDE, DOXORUBICIN HYDROCHLORIDE, METHYLPREDNISOLONE, PREDNISOLONE, RITUXIMAB, VINCRISTINE | DrugsGivenReaction | CC BY | 33509115 | 18,947,434 | 2021-01-28 |
What was the outcome of reaction 'Aspergillus infection'? | Severe Candida glabrata pancolitis and fatal Aspergillus fumigatus pulmonary infection in the setting of bone marrow aplasia after CD19-directed CAR T-cell therapy - a case report.
BACKGROUND
Prolonged myelosuppression following CD19-directed CAR T-cell transfusion represents an important, yet underreported, adverse event. The resulting neutropenia and multifactorial immunosuppression can facilitate severe infectious complications.
METHODS
We describe the clinical course of a 59-year-old patient with relapsed/refractory DLBCL who received Axicabtagene-Ciloleucel (Axi-cel). The patient developed ASTCT grade I CRS and grade IV ICANS, necessitating admission to the neurological ICU and prolonged application of high-dose corticosteroids and other immunosuppressive agents. Importantly, neutropenia was profound (ANC < 100/μl), G-CSF-refractory, and prolonged, lasting more than 50 days. The patient developed severe septic shock 3 weeks after CAR transfusion while receiving anti-fungal prophylaxis with micafungin. His clinical status stabilized with broad anti-infective treatment and intensive supportive measures. An autologous stem cell backup was employed on day 46 to support hematopoietic recovery. Although the counts of the patient eventually started to recover, he developed an invasive pulmonary aspergillosis, which ultimately lead to respiratory failure and death. Postmortem examination revealed signs of Candida glabrata pancolitis.
CONCLUSIONS
This case highlights the increased risk for fatal infectious complications in patients who present with profound and prolonged cytopenia after CAR T-cell therapy. We describe a rare case of C. glabrata pancolitis associated with multifactorial immunosuppression. Although our patient succumbed to a fatal fungal infection, autologous stem cell boost was able to spur hematopoiesis and may represent an important therapeutic strategy for DLBCL patients with CAR T-cell associated bone marrow aplasia who have underwent prior stem cell harvest.
Background
When CD19-directed Chimeric Antigen Receptor (CAR) T-cell therapies were first introduced into the clinical setting, a set of distinctive side effects were observed, including Cytokine Release Syndrome (CRS) and immune effector cell-associated neurotoxicity syndrome (ICANS). As these treatments transition from large clinical trials to real-world implementation, new nuances of the side effect spectrum have emerged. This includes the observation that patients can present not only with grade 3–4 cytopenia (CTCAE v5.0), but also a syndrome of persistent cytopenia after CAR T-cell transfusion [1, 2]. Hematologic toxicity is common with one study demonstrating that neutropenia, thrombocytopenia and anemia occur in 94, 80 and 51% of patients respectively [3]. Risk factors for hematotoxicity include CRS grade, baseline cytopenia, and prior allogeneic stem cell transplantation within the last year [2, 3]. The fact that baseline hematopoietic reserve contributes to cytopenia in CAR T-cell patients may explain the variability in the incidence of hematoxicity in the real-world setting compared to the large registration trials, which set stringent hematologic exclusion criteria [4, 5]. The clinical utility of therapeutic rescue strategies that mitigate the risk of infectious complications secondary to long-term bone marrow (BM) aplasia, such as early autologous stem cell boost or Eltrombopag, remains unknown. Moreover, the relative paucity of reports concerning severe and life-threatening infections in the reported CD19-directed CAR T-cell trials necessitates the presentation of distinctive clinical courses that underline the risks of persistent cytopenia after CAR T-cell therapy in a real-world setting.
Case presentation
The 59-year-old male patient was initially diagnosed with stage IIIA follicular lymphoma in January 2018, which transformed to germinal center B-cell like DLBCL in October of the same year. Refractory to multiple cycles of Rituximab-based immunochemotherapy (Fig. 1a), the patient underwent leukapheresis for CAR T-cell therapy in April 2019. The patient experienced significant lymphoma progression during the manufacturing process of Axicabtagene ciloleucel (Axi-cel), manifesting itself in the form of malignant pleural effusions and progressive lymphadenopathy (Fig. 2a,c,e). In the six-week period between leukapheresis and lymphodepletion, the patient remained severely neutropenic after R-CHOP and developed possible invasive fungal disease (IFD) [6] (Fig. 3e) as well as E. coli septicemia secondary to a urinary tract infection. These infections were treated successfully with liposomal amphotericin B and piperacillin/tazobactam. Prior to lymphodepletion (D-5), the patient presented with an ECOG performance status of 1, intact renal and liver function, while observing residually depressed blood counts (WBC 1270/μl, ANC 700/μl, ALC 390/μl, Hemoglobin 7.2 g/dl, Platelets 20 G/l). BM histopathology showed a hypocellular marrow with no evidence of lymphoma infiltration. Analysis of lymphocyte subpopulations demonstrated severe B-cell aplasia and decreased absolute CD4+ (84/μl) and CD8+ (271/μl) counts. His anti-infective prophylaxis consisted of a combination of acyclovir, sulfamethoxazole/trimethoprim (TMP/SMZ), and posaconazole. The fludarabine/cyclophosphamide lympho-preparative regimen was applied on days − 5 to − 3 according to the provider’s protocol, followed by CAR T-cell transfusion on day 0.
Fig. 1 Overview of CAR T-cell mediated hematotoxicity and infectious complications. a Treatment course prior to CAR T-cell therapy. b Timeline of infectious complications during CAR T-cell treatment course. Positive microbiologic culture results are underlined. Bottom: Overview of utilized anti-infectives with the respective bars displaying the length of treatment. P/T = piperacillin/tazobactam, Ami = amikacin, Mero = meropenem, Vanco = vancomycin, Line = linezolid, Posa = posaconazole (p.o.), Mica = micafungin (i.v.), Amb = liposomal amphotericin B. The patient also received prophylactic acyclovir and sulfamethoxazole/trimethoprim (TMP/SMZ) during treatment. c Complete Blood Count (CBC) timeline. ANC (blue), platelet count (green), Hemoglobin (red). Transfusion events (green: platelet transfusion, red: pRBC transfusion) and G-CSF support (blue bar) are integrated in the curve. d Dynamics of Serum Inflammatory Markers. Infectious complications are superimposed above the graph. e Histopathologic analysis of BM biopsies demonstrating severe BM aplasia 1 month after CAR T-cell transfusion (Day 32, upper panel) and evidence of recovering hematopoiesis following autologous stem cell transfer (Autopsy, lower panel). Immunohistochemical staining for myeloperoxidase (= MPO) highlighting strong activation of myelopoiesis (right panel)
Fig. 2 Radiographic evidence of partial response to Axi-cel after 36 days. Contrast-enhanced CT abdomen (axial view) displaying pleural manifestations before (a) and after (b) CAR T-cell treatment. Involved paraaortic lymph nodes (red arrows) demonstrate an interval decrease in size (c-d, e-f). The inset of panel F depicts splenic hypodensities consistent with necrosis of tumor tissue secondary to immune therapy and a reduction of splenomegaly. G Graphical depiction of response over time. Tumor extent was quantified as the sum of the product of perpendicular diameters according to Lugano criteria over 3 time points and is graphed on the y-axis. H Timeline of LDH levels (U/l). The increase in LDH levels at day 25 correlated with the gastrointestinal toxicity and liver dysfunction
Fig. 3 Multi-organ toxicity secondary to CD19-directed CAR T-cell therapy. a Contrast-enhanced CT abdomen demonstrating a non-inflamed baseline state of GI mucosal tissue prior to CAR T therapy. b Panmural swelling of the sigma (left panel), ascending colon (middle panel), and stomach. c Non-pathologic CT of the brain. d Axial FLAIR-weighted (left), T1-weighted contrast-enhanced (middle), and diffusion-weighted (right) MRI displaying no evidence of cerebral edema, white matter lesions, diffusion restriction, microbleeds, meningeal enhancement or contrast enhancing lesions. e High-resolution CT thorax with bilateral fungal infiltrates observing the typical halo configuration 6 weeks prior to CAR T-cell transfusion. f On day − 3 the right-sided infiltrates have decreased in size. The left lung is collapsed due to malignant pleural effusion. g Lung parenchyma exhibiting an infiltration of non-dimorphic blastoconidial morphology consistent with Candida glabrata. h PAS staining of a lung specimen highlights septated hiphae and acute-angle branching, features consistent of with aspergillus infection
During lymphodepletion the patient developed an upper respiratory infection, presenting with a non-productive cough and a sputum culture positive for Bordetella bronchiseptica, which resolved clinically after antibiotic treatment with piperacillin/tazobactam. On day 7, the patient developed fever with a stable cardiopulmonary function and concomitant IL-6 rise (Fig. 1d), which was classified as CRS grade I according to ASTCT consensus grading [7] in the absence of positive blood cultures and other foci. Due to persistent fever refractory to antipyretic treatment, four total doses of tocilizumab (8 mg/kg) were applied over 36 h. Starting on day 9, the patient deteriorated neurologically with a depressed state of consciousness prompting the diagnosis of grade IV ICANS. The patient was transferred to the neurological ICU, and high-dose corticosteroids (methylprednisolone 1000 mg daily) were initiated. CSF-analysis displayed subtle pleocytosis, but revealed no signs of CNS infection (viral, bacterial and fungal) or meningeal involvement of the DLBCL. CT and MR imaging of the brain exhibited none of the pathological findings reported for ICANS [8] or CNS infection [9](Fig. 3c-d). After 5 days of high-dose methylprednisolone, the patient’s neurological status slowly improved, and corticosteroids could be tapered.
Partial response to Axicabtagene-Ciloleucel after 36 days according to Lugano criteria
While the patient’s initial clinical course was fraught with complications, CT staging performed at day 36 demonstrated a partial response to CAR T-cell therapy according to Lugano and Lyric criteria (Fig. 2a-g). This was particularly evident for the pleural manifestations of the underlying DLBCL, which was accompanied by an interval decrease in pleural effusions and subjective dyspnea (Fig. 2a-b). Multiple nodal sites including paraaortic (Fig. 2c-d) and parailiac lymph nodes (Fig. 2e-f) exhibited significant regression of tumor size (Fig. 2g). Moreover, the patient displayed splenic hypodensities consistent with either tumor tissue necrosis or infection-associated inflammatory changes (inset, Fig. 2f). These CT-morphologic findings were accompanied by a decrease of LDH levels (Fig. 2h).
Prolonged cytopenia lead to the development of severe neutropenic colitis and fatal fungal pneumonia
The patient presented with significant myelotoxicity and sustained transfusion dependency after CAR T-cell administration (Fig. 1c). The overall duration of profound neutropenia – defined as an ANC < 100/μl [10] – was 52 days. Because of the severity of ICANS, the clinicians chose to hold G-CSF during this time period due to concerns for risk of worsening toxicity [11].
While receiving broad anti-infectives (acyclovir, TMP/SMZ, posaconazole, meropenem), the patient developed breakthrough septic shock on day 24. He exhibited fever (39.5 °C), hypotension (70/30 mmHg), tachycardia (160/min), as well as lactic acidosis (lactate: 10.7 mmol/l). The patient was non-conversant, non-oriented, and was not able to localize symptoms. However, he had described epigastric tenderness and subtle changes in stool consistency and frequency on the previous day. As a result, abdominal CT imaging was obtained, which displayed severe pancolitis, as evidenced by pronounced mucosal thickening with edematous changes ranging from the ascending colon to the rectum (Fig. 3a-b). Labs were notable for an acute spike of serum inflammatory parameters (Il-6 > 500.000 pg/ml, CRP 5.7 mg/dl, Procalcitonin 11.2 ng/ml, Fig. 1d). Following ICU transfer, high-dose vasopressor support with norepinephrine was initiated together with volume resuscitation to maintain organ perfusion. Due to progressive loss of consciousness the patient was intubated and mechanically ventilated. To control the proinflammatory state, extracorporeal cytokine absorption (Cytosorb®) was performed, which resulted in a decrease of soluble inflammatory markers in the subsequent days. Arterial blood cultures were positive for vancomycin-resistant enterococci (VRE), and the antibiotic treatment was escalated to include linezolid along with meropenem (Fig. 1b). The ICU team transitioned antifungal prophylaxis from posaconazole to an echinocandine (micafungin 50 mg IV) due to ECG changes and concerns for drug interactions on day 24. Though he remained in critical condition, in the coming weeks his clinical condition stabilized and both the catecholamine rate and volume support could be reduced. To determine the origin of sustained myelosuppression, a bone marrow biopsy was obtained, which depicted a hypocellular marrow and severe aplasia affecting all hematopoietic lineages (Fig. 1e). On days 41 and 49, surveillance blood cultures were positive for Candida glabrata, a commensal fungal organism of human mucosal tissues [12] harboring an intrinsic azole resistance [13]. Susceptibility testing confirmed the azole-resistance of C. glabrata isolates. The antimycotic therapy was escalated from micafungin to liposomal amphotericin B. C. glabrata likely disseminated to the bloodstream secondary to the described gastrointestinal toxicity and was previously discovered on rectal swab (Fig. 1b) and fecal culture (day − 51).
Due to sustained neutropenia, BM aplasia and the availability of a suitable apheresis product, the CAR T-cell Taskforce proceeded with a stem cell boost of previously collected autologous CD34+ cells (3,1 × 106 cells) on day 46. The combination of a sudden rise in serum inflammatory markers and a strongly positive serum galactomannan (GM) assay on day 49 prompted diagnostic bronchoscopy, which revealed a diffuse infiltrate of alveolar and peri-bronchial tissue by Aspergillus fumigatus, consistent with fulminant invasive fungal pneumonia. Over the next week, the patient became increasingly hemodynamically unstable with poor peripheral oxygenation. Repeat bronchoscopy with bronchial lavage was positive for A. fumigatus and C. glabrata. After 50 days of G-CSF refractory aplasia, the autologous stem cells slowly engrafted leading to neutrophil recovery. However, this likely exacerbated the local inflammatory reaction in the lung, contributing to rapid deterioration of his respiratory status. Despite extensive supportive measures, the patient died on day 58 after CAR T-cell transfusion. Cause of death was confirmed by autopsy as invasive fungal pneumonia with multi-organ septic spread. Post-mortem examination revealed Candida spores in intestinal, colonic and rectal tissue. Of note, histopathologic BM analysis revealed signs of burgeoning hematopoietic regeneration (Fig. 1e).
Discussion and conclusions
Recent studies have shed light on the high incidence of prolonged and profound neutropenia after adoptive immunotherapy with CD19-specific CAR T-cells [1–3]. Clinical sequalae include severe infectious complications, which have emerged as the number one cause of long-term non-relapse mortality after CAR T-cell therapy [14]. In a seminal study, Hill and colleagues demonstrate that infectious complications are common with a cumulative incidence of 23% in the first 28 days after CAR T-cell transfusion and 14% between days 29–90. While bacterial infections were most common in the first month, viral infections – especially respiratory viruses – predominated after day 29, likely as a result of an impaired adaptive immune response due to B-cell aplasia [15]. Overall, most infections were mild to moderate and fatal infections were rare. Invasive mold infections were uncommon, ranging from 1 to 7% in CAR T-cell recipients [15–17]. In multivariate analyses, the use of systemic corticosteroids for the management of CRS or ICANS has emerged as a major risk factor of infection [18]. Certain inflammatory signatures – such as the “double peaks of IL-6” pattern observed in our patient – have been shown to confer an especially high risk of life-threatening infection [19].
This case highlights the combination of factors that precipitate a high risk of infectious complications in a CAR T-cell patient. First, the heavily pre-treated patient displayed B-cell aplasia and a diminished hematopoietic reserve (e.g. trilineage cytopenia) prior to lymphodepletion. Second, the patient developed classic complications of CAR T-cell therapy such as CRS and severe and prolonged ICANS, reflecting a pro-inflammatory state that represents an important risk factor for developing infections in CAR T-cell patients [16]. The subsequent application of high-dose corticosteroids impaired both innate and adaptive immunity [20]. Third, pancytopenia was profound, prolonged and not able to be reverted by growth factor support. Fourth, the patient had a history of infectious complications, including a course of fungal pneumonia 6 weeks prior to lymphodepletion, likely flaring up in the setting of the above three factors.
Our patient developed severe septic shock secondary to neutropenic colitis on day 24, highlighting the risk of a watch-and-wait approach to prolonged neutropenia after CAR T-cell therapy. A two-pronged approach to management appears prescient. On the one hand, measures to propagate hematopoietic recovery should be exhausted (causal therapy). This can range from G-CSF stimulation, to a trial of pulse-dose corticosteroids or anti-cytokine therapy (e.g. Anakinra, Tocilizumab), to a stem cell boost as a last resort in lymphoma patients who have undergone prior autologous stem cell transplantation. On the other hand, clinicians should be at high alert for infectious complications and adapt their infection surveillance and anti-infective prophylactic strategies accordingly. For example, therapeutic drug monitoring of posaconazole and meropenem levels may have revealed subtherapeutic dosing of these anti-infective agents in this patient [21]. The role of antifungal prophylaxis in the CAR T-cell patient remains inconclusive. Adequately powered studies addressing the duration of neutropenia after CAR T-cell therapy, and potential clinical determinants of invasive fungal infections, will be critical to gauge the benefit of antifungal prophylaxis in this patient collective.
Candida species are a leading cause of fungus-associated morbidity and mortality in severely immunocompromised patients [21]. On day 41, this patient developed breakthrough C. glabrata Candidemia on micafungin, in the setting of both underlying colonization and neutropenic colitis. A recent report implicated the gastrointestinal tract as major source of echinocandin drug resistance in a murine model of C. glabrata colonization and systemic dissemination [22]. Of note, breakthrough Candida infections on micafungin may occur at the employed dose level (50 mg/day IV), suggesting that this dose may have been inadequate to prevent subsequent Candidemia [23]. Though cases of C. glabrata colitis are extremely rare [24], an opportunistic infection could not be ruled out given that C. glabrata infiltrates were discovered in enteral and colonic mucosal tissue on post-mortem examination. Importantly, the patients’ clinical status deteriorated only after the stem cell boost resulted in signs of hematopoietic recovery. The paradoxical worsening of the pulmonary A. fumigatus infection is consistent with immune reconstitution inflammatory syndrome (IRIS), which has been previously described for HIV/AIDS [25] and for severely neutropenic patients with IPA [26]. In conclusion, this case emphasizes that infectious complications secondary to prolonged cytopenia influence non-relapse mortality after CAR T-cell therapy.
Abbreviations
ALCAbsolute Lymphocyte Count
ANCAbsolute Neutrophil Count
BMBone Marrow
CARChimeric antigen receptor
CBCComplete Blood Count
CRSCytokine release syndrome
CTCAECommon Terminology Criteria for Adverse Events
DLBCLDiffuse large B-cell lymphoma
FFPFresh frozen plasma
FLAIRFluid-attenuated inversion recovery
Flu/CyFludarabine/Cyclophosphamide
G-CSFGranulocyte colony stimulating factor
GIGastrointestinal
GMGalactomannan
HSPCsHematopoietic stem and progenitor cells
ICANSImmune effector cell-associated neurotoxicity syndrome
ICE-scoreImmune Effector Cell-associated Encephalopathy score
ICUIntensive care unit
IPAInvasive pulmonary aspergillosis
LDHLactate Dehydrogenase
LYRICLymphoma response to immunomodulatory therapy criteria
MDRDModification of Diet in Renal Disease
MPOMyeloperoxidase
PASPeriodic acid-Schiff
PBSCPeripheral Blood Stem Cell
VREVancomycin-resistant Enterococcus
WBCWhite Blood Count
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Acknowledgements
Not applicable.
Authors’ contributions
The original manuscript was written by KR. KR and WGK prepared the figures. MR performed the histological examination of the bone marrow. MS reviewed and edited the manuscript. The other authors (VB1, VB2, CS, PK, FS, KD, LvB, JS, OW, MD, MvBB) contributed to patient management and participated in drafting and editing the manuscript. All authors read and approved the final manuscript.
Funding
Not applicable. Open Access funding enabled and organized by Projekt DEAL.
Availability of data and materials
The authors did not use any database, software, or tools for the writing of this manuscript.
Ethics approval and consent to participate
The authors obtained consent from the deceased patient’s next-of-kin to participate.
Consent for publication
Written informed consent was obtained from the patient’s next-of-kin for publication of this Case report and any accompanying images. A copy of the written consent is available for review by the Editor of this journal.
Competing interests
The authors declare that they have no competing interests related with this case report. | Fatal | ReactionOutcome | CC BY | 33509115 | 18,947,434 | 2021-01-28 |
What was the outcome of reaction 'Bronchopulmonary aspergillosis'? | Severe Candida glabrata pancolitis and fatal Aspergillus fumigatus pulmonary infection in the setting of bone marrow aplasia after CD19-directed CAR T-cell therapy - a case report.
BACKGROUND
Prolonged myelosuppression following CD19-directed CAR T-cell transfusion represents an important, yet underreported, adverse event. The resulting neutropenia and multifactorial immunosuppression can facilitate severe infectious complications.
METHODS
We describe the clinical course of a 59-year-old patient with relapsed/refractory DLBCL who received Axicabtagene-Ciloleucel (Axi-cel). The patient developed ASTCT grade I CRS and grade IV ICANS, necessitating admission to the neurological ICU and prolonged application of high-dose corticosteroids and other immunosuppressive agents. Importantly, neutropenia was profound (ANC < 100/μl), G-CSF-refractory, and prolonged, lasting more than 50 days. The patient developed severe septic shock 3 weeks after CAR transfusion while receiving anti-fungal prophylaxis with micafungin. His clinical status stabilized with broad anti-infective treatment and intensive supportive measures. An autologous stem cell backup was employed on day 46 to support hematopoietic recovery. Although the counts of the patient eventually started to recover, he developed an invasive pulmonary aspergillosis, which ultimately lead to respiratory failure and death. Postmortem examination revealed signs of Candida glabrata pancolitis.
CONCLUSIONS
This case highlights the increased risk for fatal infectious complications in patients who present with profound and prolonged cytopenia after CAR T-cell therapy. We describe a rare case of C. glabrata pancolitis associated with multifactorial immunosuppression. Although our patient succumbed to a fatal fungal infection, autologous stem cell boost was able to spur hematopoiesis and may represent an important therapeutic strategy for DLBCL patients with CAR T-cell associated bone marrow aplasia who have underwent prior stem cell harvest.
Background
When CD19-directed Chimeric Antigen Receptor (CAR) T-cell therapies were first introduced into the clinical setting, a set of distinctive side effects were observed, including Cytokine Release Syndrome (CRS) and immune effector cell-associated neurotoxicity syndrome (ICANS). As these treatments transition from large clinical trials to real-world implementation, new nuances of the side effect spectrum have emerged. This includes the observation that patients can present not only with grade 3–4 cytopenia (CTCAE v5.0), but also a syndrome of persistent cytopenia after CAR T-cell transfusion [1, 2]. Hematologic toxicity is common with one study demonstrating that neutropenia, thrombocytopenia and anemia occur in 94, 80 and 51% of patients respectively [3]. Risk factors for hematotoxicity include CRS grade, baseline cytopenia, and prior allogeneic stem cell transplantation within the last year [2, 3]. The fact that baseline hematopoietic reserve contributes to cytopenia in CAR T-cell patients may explain the variability in the incidence of hematoxicity in the real-world setting compared to the large registration trials, which set stringent hematologic exclusion criteria [4, 5]. The clinical utility of therapeutic rescue strategies that mitigate the risk of infectious complications secondary to long-term bone marrow (BM) aplasia, such as early autologous stem cell boost or Eltrombopag, remains unknown. Moreover, the relative paucity of reports concerning severe and life-threatening infections in the reported CD19-directed CAR T-cell trials necessitates the presentation of distinctive clinical courses that underline the risks of persistent cytopenia after CAR T-cell therapy in a real-world setting.
Case presentation
The 59-year-old male patient was initially diagnosed with stage IIIA follicular lymphoma in January 2018, which transformed to germinal center B-cell like DLBCL in October of the same year. Refractory to multiple cycles of Rituximab-based immunochemotherapy (Fig. 1a), the patient underwent leukapheresis for CAR T-cell therapy in April 2019. The patient experienced significant lymphoma progression during the manufacturing process of Axicabtagene ciloleucel (Axi-cel), manifesting itself in the form of malignant pleural effusions and progressive lymphadenopathy (Fig. 2a,c,e). In the six-week period between leukapheresis and lymphodepletion, the patient remained severely neutropenic after R-CHOP and developed possible invasive fungal disease (IFD) [6] (Fig. 3e) as well as E. coli septicemia secondary to a urinary tract infection. These infections were treated successfully with liposomal amphotericin B and piperacillin/tazobactam. Prior to lymphodepletion (D-5), the patient presented with an ECOG performance status of 1, intact renal and liver function, while observing residually depressed blood counts (WBC 1270/μl, ANC 700/μl, ALC 390/μl, Hemoglobin 7.2 g/dl, Platelets 20 G/l). BM histopathology showed a hypocellular marrow with no evidence of lymphoma infiltration. Analysis of lymphocyte subpopulations demonstrated severe B-cell aplasia and decreased absolute CD4+ (84/μl) and CD8+ (271/μl) counts. His anti-infective prophylaxis consisted of a combination of acyclovir, sulfamethoxazole/trimethoprim (TMP/SMZ), and posaconazole. The fludarabine/cyclophosphamide lympho-preparative regimen was applied on days − 5 to − 3 according to the provider’s protocol, followed by CAR T-cell transfusion on day 0.
Fig. 1 Overview of CAR T-cell mediated hematotoxicity and infectious complications. a Treatment course prior to CAR T-cell therapy. b Timeline of infectious complications during CAR T-cell treatment course. Positive microbiologic culture results are underlined. Bottom: Overview of utilized anti-infectives with the respective bars displaying the length of treatment. P/T = piperacillin/tazobactam, Ami = amikacin, Mero = meropenem, Vanco = vancomycin, Line = linezolid, Posa = posaconazole (p.o.), Mica = micafungin (i.v.), Amb = liposomal amphotericin B. The patient also received prophylactic acyclovir and sulfamethoxazole/trimethoprim (TMP/SMZ) during treatment. c Complete Blood Count (CBC) timeline. ANC (blue), platelet count (green), Hemoglobin (red). Transfusion events (green: platelet transfusion, red: pRBC transfusion) and G-CSF support (blue bar) are integrated in the curve. d Dynamics of Serum Inflammatory Markers. Infectious complications are superimposed above the graph. e Histopathologic analysis of BM biopsies demonstrating severe BM aplasia 1 month after CAR T-cell transfusion (Day 32, upper panel) and evidence of recovering hematopoiesis following autologous stem cell transfer (Autopsy, lower panel). Immunohistochemical staining for myeloperoxidase (= MPO) highlighting strong activation of myelopoiesis (right panel)
Fig. 2 Radiographic evidence of partial response to Axi-cel after 36 days. Contrast-enhanced CT abdomen (axial view) displaying pleural manifestations before (a) and after (b) CAR T-cell treatment. Involved paraaortic lymph nodes (red arrows) demonstrate an interval decrease in size (c-d, e-f). The inset of panel F depicts splenic hypodensities consistent with necrosis of tumor tissue secondary to immune therapy and a reduction of splenomegaly. G Graphical depiction of response over time. Tumor extent was quantified as the sum of the product of perpendicular diameters according to Lugano criteria over 3 time points and is graphed on the y-axis. H Timeline of LDH levels (U/l). The increase in LDH levels at day 25 correlated with the gastrointestinal toxicity and liver dysfunction
Fig. 3 Multi-organ toxicity secondary to CD19-directed CAR T-cell therapy. a Contrast-enhanced CT abdomen demonstrating a non-inflamed baseline state of GI mucosal tissue prior to CAR T therapy. b Panmural swelling of the sigma (left panel), ascending colon (middle panel), and stomach. c Non-pathologic CT of the brain. d Axial FLAIR-weighted (left), T1-weighted contrast-enhanced (middle), and diffusion-weighted (right) MRI displaying no evidence of cerebral edema, white matter lesions, diffusion restriction, microbleeds, meningeal enhancement or contrast enhancing lesions. e High-resolution CT thorax with bilateral fungal infiltrates observing the typical halo configuration 6 weeks prior to CAR T-cell transfusion. f On day − 3 the right-sided infiltrates have decreased in size. The left lung is collapsed due to malignant pleural effusion. g Lung parenchyma exhibiting an infiltration of non-dimorphic blastoconidial morphology consistent with Candida glabrata. h PAS staining of a lung specimen highlights septated hiphae and acute-angle branching, features consistent of with aspergillus infection
During lymphodepletion the patient developed an upper respiratory infection, presenting with a non-productive cough and a sputum culture positive for Bordetella bronchiseptica, which resolved clinically after antibiotic treatment with piperacillin/tazobactam. On day 7, the patient developed fever with a stable cardiopulmonary function and concomitant IL-6 rise (Fig. 1d), which was classified as CRS grade I according to ASTCT consensus grading [7] in the absence of positive blood cultures and other foci. Due to persistent fever refractory to antipyretic treatment, four total doses of tocilizumab (8 mg/kg) were applied over 36 h. Starting on day 9, the patient deteriorated neurologically with a depressed state of consciousness prompting the diagnosis of grade IV ICANS. The patient was transferred to the neurological ICU, and high-dose corticosteroids (methylprednisolone 1000 mg daily) were initiated. CSF-analysis displayed subtle pleocytosis, but revealed no signs of CNS infection (viral, bacterial and fungal) or meningeal involvement of the DLBCL. CT and MR imaging of the brain exhibited none of the pathological findings reported for ICANS [8] or CNS infection [9](Fig. 3c-d). After 5 days of high-dose methylprednisolone, the patient’s neurological status slowly improved, and corticosteroids could be tapered.
Partial response to Axicabtagene-Ciloleucel after 36 days according to Lugano criteria
While the patient’s initial clinical course was fraught with complications, CT staging performed at day 36 demonstrated a partial response to CAR T-cell therapy according to Lugano and Lyric criteria (Fig. 2a-g). This was particularly evident for the pleural manifestations of the underlying DLBCL, which was accompanied by an interval decrease in pleural effusions and subjective dyspnea (Fig. 2a-b). Multiple nodal sites including paraaortic (Fig. 2c-d) and parailiac lymph nodes (Fig. 2e-f) exhibited significant regression of tumor size (Fig. 2g). Moreover, the patient displayed splenic hypodensities consistent with either tumor tissue necrosis or infection-associated inflammatory changes (inset, Fig. 2f). These CT-morphologic findings were accompanied by a decrease of LDH levels (Fig. 2h).
Prolonged cytopenia lead to the development of severe neutropenic colitis and fatal fungal pneumonia
The patient presented with significant myelotoxicity and sustained transfusion dependency after CAR T-cell administration (Fig. 1c). The overall duration of profound neutropenia – defined as an ANC < 100/μl [10] – was 52 days. Because of the severity of ICANS, the clinicians chose to hold G-CSF during this time period due to concerns for risk of worsening toxicity [11].
While receiving broad anti-infectives (acyclovir, TMP/SMZ, posaconazole, meropenem), the patient developed breakthrough septic shock on day 24. He exhibited fever (39.5 °C), hypotension (70/30 mmHg), tachycardia (160/min), as well as lactic acidosis (lactate: 10.7 mmol/l). The patient was non-conversant, non-oriented, and was not able to localize symptoms. However, he had described epigastric tenderness and subtle changes in stool consistency and frequency on the previous day. As a result, abdominal CT imaging was obtained, which displayed severe pancolitis, as evidenced by pronounced mucosal thickening with edematous changes ranging from the ascending colon to the rectum (Fig. 3a-b). Labs were notable for an acute spike of serum inflammatory parameters (Il-6 > 500.000 pg/ml, CRP 5.7 mg/dl, Procalcitonin 11.2 ng/ml, Fig. 1d). Following ICU transfer, high-dose vasopressor support with norepinephrine was initiated together with volume resuscitation to maintain organ perfusion. Due to progressive loss of consciousness the patient was intubated and mechanically ventilated. To control the proinflammatory state, extracorporeal cytokine absorption (Cytosorb®) was performed, which resulted in a decrease of soluble inflammatory markers in the subsequent days. Arterial blood cultures were positive for vancomycin-resistant enterococci (VRE), and the antibiotic treatment was escalated to include linezolid along with meropenem (Fig. 1b). The ICU team transitioned antifungal prophylaxis from posaconazole to an echinocandine (micafungin 50 mg IV) due to ECG changes and concerns for drug interactions on day 24. Though he remained in critical condition, in the coming weeks his clinical condition stabilized and both the catecholamine rate and volume support could be reduced. To determine the origin of sustained myelosuppression, a bone marrow biopsy was obtained, which depicted a hypocellular marrow and severe aplasia affecting all hematopoietic lineages (Fig. 1e). On days 41 and 49, surveillance blood cultures were positive for Candida glabrata, a commensal fungal organism of human mucosal tissues [12] harboring an intrinsic azole resistance [13]. Susceptibility testing confirmed the azole-resistance of C. glabrata isolates. The antimycotic therapy was escalated from micafungin to liposomal amphotericin B. C. glabrata likely disseminated to the bloodstream secondary to the described gastrointestinal toxicity and was previously discovered on rectal swab (Fig. 1b) and fecal culture (day − 51).
Due to sustained neutropenia, BM aplasia and the availability of a suitable apheresis product, the CAR T-cell Taskforce proceeded with a stem cell boost of previously collected autologous CD34+ cells (3,1 × 106 cells) on day 46. The combination of a sudden rise in serum inflammatory markers and a strongly positive serum galactomannan (GM) assay on day 49 prompted diagnostic bronchoscopy, which revealed a diffuse infiltrate of alveolar and peri-bronchial tissue by Aspergillus fumigatus, consistent with fulminant invasive fungal pneumonia. Over the next week, the patient became increasingly hemodynamically unstable with poor peripheral oxygenation. Repeat bronchoscopy with bronchial lavage was positive for A. fumigatus and C. glabrata. After 50 days of G-CSF refractory aplasia, the autologous stem cells slowly engrafted leading to neutrophil recovery. However, this likely exacerbated the local inflammatory reaction in the lung, contributing to rapid deterioration of his respiratory status. Despite extensive supportive measures, the patient died on day 58 after CAR T-cell transfusion. Cause of death was confirmed by autopsy as invasive fungal pneumonia with multi-organ septic spread. Post-mortem examination revealed Candida spores in intestinal, colonic and rectal tissue. Of note, histopathologic BM analysis revealed signs of burgeoning hematopoietic regeneration (Fig. 1e).
Discussion and conclusions
Recent studies have shed light on the high incidence of prolonged and profound neutropenia after adoptive immunotherapy with CD19-specific CAR T-cells [1–3]. Clinical sequalae include severe infectious complications, which have emerged as the number one cause of long-term non-relapse mortality after CAR T-cell therapy [14]. In a seminal study, Hill and colleagues demonstrate that infectious complications are common with a cumulative incidence of 23% in the first 28 days after CAR T-cell transfusion and 14% between days 29–90. While bacterial infections were most common in the first month, viral infections – especially respiratory viruses – predominated after day 29, likely as a result of an impaired adaptive immune response due to B-cell aplasia [15]. Overall, most infections were mild to moderate and fatal infections were rare. Invasive mold infections were uncommon, ranging from 1 to 7% in CAR T-cell recipients [15–17]. In multivariate analyses, the use of systemic corticosteroids for the management of CRS or ICANS has emerged as a major risk factor of infection [18]. Certain inflammatory signatures – such as the “double peaks of IL-6” pattern observed in our patient – have been shown to confer an especially high risk of life-threatening infection [19].
This case highlights the combination of factors that precipitate a high risk of infectious complications in a CAR T-cell patient. First, the heavily pre-treated patient displayed B-cell aplasia and a diminished hematopoietic reserve (e.g. trilineage cytopenia) prior to lymphodepletion. Second, the patient developed classic complications of CAR T-cell therapy such as CRS and severe and prolonged ICANS, reflecting a pro-inflammatory state that represents an important risk factor for developing infections in CAR T-cell patients [16]. The subsequent application of high-dose corticosteroids impaired both innate and adaptive immunity [20]. Third, pancytopenia was profound, prolonged and not able to be reverted by growth factor support. Fourth, the patient had a history of infectious complications, including a course of fungal pneumonia 6 weeks prior to lymphodepletion, likely flaring up in the setting of the above three factors.
Our patient developed severe septic shock secondary to neutropenic colitis on day 24, highlighting the risk of a watch-and-wait approach to prolonged neutropenia after CAR T-cell therapy. A two-pronged approach to management appears prescient. On the one hand, measures to propagate hematopoietic recovery should be exhausted (causal therapy). This can range from G-CSF stimulation, to a trial of pulse-dose corticosteroids or anti-cytokine therapy (e.g. Anakinra, Tocilizumab), to a stem cell boost as a last resort in lymphoma patients who have undergone prior autologous stem cell transplantation. On the other hand, clinicians should be at high alert for infectious complications and adapt their infection surveillance and anti-infective prophylactic strategies accordingly. For example, therapeutic drug monitoring of posaconazole and meropenem levels may have revealed subtherapeutic dosing of these anti-infective agents in this patient [21]. The role of antifungal prophylaxis in the CAR T-cell patient remains inconclusive. Adequately powered studies addressing the duration of neutropenia after CAR T-cell therapy, and potential clinical determinants of invasive fungal infections, will be critical to gauge the benefit of antifungal prophylaxis in this patient collective.
Candida species are a leading cause of fungus-associated morbidity and mortality in severely immunocompromised patients [21]. On day 41, this patient developed breakthrough C. glabrata Candidemia on micafungin, in the setting of both underlying colonization and neutropenic colitis. A recent report implicated the gastrointestinal tract as major source of echinocandin drug resistance in a murine model of C. glabrata colonization and systemic dissemination [22]. Of note, breakthrough Candida infections on micafungin may occur at the employed dose level (50 mg/day IV), suggesting that this dose may have been inadequate to prevent subsequent Candidemia [23]. Though cases of C. glabrata colitis are extremely rare [24], an opportunistic infection could not be ruled out given that C. glabrata infiltrates were discovered in enteral and colonic mucosal tissue on post-mortem examination. Importantly, the patients’ clinical status deteriorated only after the stem cell boost resulted in signs of hematopoietic recovery. The paradoxical worsening of the pulmonary A. fumigatus infection is consistent with immune reconstitution inflammatory syndrome (IRIS), which has been previously described for HIV/AIDS [25] and for severely neutropenic patients with IPA [26]. In conclusion, this case emphasizes that infectious complications secondary to prolonged cytopenia influence non-relapse mortality after CAR T-cell therapy.
Abbreviations
ALCAbsolute Lymphocyte Count
ANCAbsolute Neutrophil Count
BMBone Marrow
CARChimeric antigen receptor
CBCComplete Blood Count
CRSCytokine release syndrome
CTCAECommon Terminology Criteria for Adverse Events
DLBCLDiffuse large B-cell lymphoma
FFPFresh frozen plasma
FLAIRFluid-attenuated inversion recovery
Flu/CyFludarabine/Cyclophosphamide
G-CSFGranulocyte colony stimulating factor
GIGastrointestinal
GMGalactomannan
HSPCsHematopoietic stem and progenitor cells
ICANSImmune effector cell-associated neurotoxicity syndrome
ICE-scoreImmune Effector Cell-associated Encephalopathy score
ICUIntensive care unit
IPAInvasive pulmonary aspergillosis
LDHLactate Dehydrogenase
LYRICLymphoma response to immunomodulatory therapy criteria
MDRDModification of Diet in Renal Disease
MPOMyeloperoxidase
PASPeriodic acid-Schiff
PBSCPeripheral Blood Stem Cell
VREVancomycin-resistant Enterococcus
WBCWhite Blood Count
Publisher’s Note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
Acknowledgements
Not applicable.
Authors’ contributions
The original manuscript was written by KR. KR and WGK prepared the figures. MR performed the histological examination of the bone marrow. MS reviewed and edited the manuscript. The other authors (VB1, VB2, CS, PK, FS, KD, LvB, JS, OW, MD, MvBB) contributed to patient management and participated in drafting and editing the manuscript. All authors read and approved the final manuscript.
Funding
Not applicable. Open Access funding enabled and organized by Projekt DEAL.
Availability of data and materials
The authors did not use any database, software, or tools for the writing of this manuscript.
Ethics approval and consent to participate
The authors obtained consent from the deceased patient’s next-of-kin to participate.
Consent for publication
Written informed consent was obtained from the patient’s next-of-kin for publication of this Case report and any accompanying images. A copy of the written consent is available for review by the Editor of this journal.
Competing interests
The authors declare that they have no competing interests related with this case report. | Fatal | ReactionOutcome | CC BY | 33509115 | 18,947,434 | 2021-01-28 |
What was the outcome of reaction 'Candida infection'? | Severe Candida glabrata pancolitis and fatal Aspergillus fumigatus pulmonary infection in the setting of bone marrow aplasia after CD19-directed CAR T-cell therapy - a case report.
BACKGROUND
Prolonged myelosuppression following CD19-directed CAR T-cell transfusion represents an important, yet underreported, adverse event. The resulting neutropenia and multifactorial immunosuppression can facilitate severe infectious complications.
METHODS
We describe the clinical course of a 59-year-old patient with relapsed/refractory DLBCL who received Axicabtagene-Ciloleucel (Axi-cel). The patient developed ASTCT grade I CRS and grade IV ICANS, necessitating admission to the neurological ICU and prolonged application of high-dose corticosteroids and other immunosuppressive agents. Importantly, neutropenia was profound (ANC < 100/μl), G-CSF-refractory, and prolonged, lasting more than 50 days. The patient developed severe septic shock 3 weeks after CAR transfusion while receiving anti-fungal prophylaxis with micafungin. His clinical status stabilized with broad anti-infective treatment and intensive supportive measures. An autologous stem cell backup was employed on day 46 to support hematopoietic recovery. Although the counts of the patient eventually started to recover, he developed an invasive pulmonary aspergillosis, which ultimately lead to respiratory failure and death. Postmortem examination revealed signs of Candida glabrata pancolitis.
CONCLUSIONS
This case highlights the increased risk for fatal infectious complications in patients who present with profound and prolonged cytopenia after CAR T-cell therapy. We describe a rare case of C. glabrata pancolitis associated with multifactorial immunosuppression. Although our patient succumbed to a fatal fungal infection, autologous stem cell boost was able to spur hematopoiesis and may represent an important therapeutic strategy for DLBCL patients with CAR T-cell associated bone marrow aplasia who have underwent prior stem cell harvest.
Background
When CD19-directed Chimeric Antigen Receptor (CAR) T-cell therapies were first introduced into the clinical setting, a set of distinctive side effects were observed, including Cytokine Release Syndrome (CRS) and immune effector cell-associated neurotoxicity syndrome (ICANS). As these treatments transition from large clinical trials to real-world implementation, new nuances of the side effect spectrum have emerged. This includes the observation that patients can present not only with grade 3–4 cytopenia (CTCAE v5.0), but also a syndrome of persistent cytopenia after CAR T-cell transfusion [1, 2]. Hematologic toxicity is common with one study demonstrating that neutropenia, thrombocytopenia and anemia occur in 94, 80 and 51% of patients respectively [3]. Risk factors for hematotoxicity include CRS grade, baseline cytopenia, and prior allogeneic stem cell transplantation within the last year [2, 3]. The fact that baseline hematopoietic reserve contributes to cytopenia in CAR T-cell patients may explain the variability in the incidence of hematoxicity in the real-world setting compared to the large registration trials, which set stringent hematologic exclusion criteria [4, 5]. The clinical utility of therapeutic rescue strategies that mitigate the risk of infectious complications secondary to long-term bone marrow (BM) aplasia, such as early autologous stem cell boost or Eltrombopag, remains unknown. Moreover, the relative paucity of reports concerning severe and life-threatening infections in the reported CD19-directed CAR T-cell trials necessitates the presentation of distinctive clinical courses that underline the risks of persistent cytopenia after CAR T-cell therapy in a real-world setting.
Case presentation
The 59-year-old male patient was initially diagnosed with stage IIIA follicular lymphoma in January 2018, which transformed to germinal center B-cell like DLBCL in October of the same year. Refractory to multiple cycles of Rituximab-based immunochemotherapy (Fig. 1a), the patient underwent leukapheresis for CAR T-cell therapy in April 2019. The patient experienced significant lymphoma progression during the manufacturing process of Axicabtagene ciloleucel (Axi-cel), manifesting itself in the form of malignant pleural effusions and progressive lymphadenopathy (Fig. 2a,c,e). In the six-week period between leukapheresis and lymphodepletion, the patient remained severely neutropenic after R-CHOP and developed possible invasive fungal disease (IFD) [6] (Fig. 3e) as well as E. coli septicemia secondary to a urinary tract infection. These infections were treated successfully with liposomal amphotericin B and piperacillin/tazobactam. Prior to lymphodepletion (D-5), the patient presented with an ECOG performance status of 1, intact renal and liver function, while observing residually depressed blood counts (WBC 1270/μl, ANC 700/μl, ALC 390/μl, Hemoglobin 7.2 g/dl, Platelets 20 G/l). BM histopathology showed a hypocellular marrow with no evidence of lymphoma infiltration. Analysis of lymphocyte subpopulations demonstrated severe B-cell aplasia and decreased absolute CD4+ (84/μl) and CD8+ (271/μl) counts. His anti-infective prophylaxis consisted of a combination of acyclovir, sulfamethoxazole/trimethoprim (TMP/SMZ), and posaconazole. The fludarabine/cyclophosphamide lympho-preparative regimen was applied on days − 5 to − 3 according to the provider’s protocol, followed by CAR T-cell transfusion on day 0.
Fig. 1 Overview of CAR T-cell mediated hematotoxicity and infectious complications. a Treatment course prior to CAR T-cell therapy. b Timeline of infectious complications during CAR T-cell treatment course. Positive microbiologic culture results are underlined. Bottom: Overview of utilized anti-infectives with the respective bars displaying the length of treatment. P/T = piperacillin/tazobactam, Ami = amikacin, Mero = meropenem, Vanco = vancomycin, Line = linezolid, Posa = posaconazole (p.o.), Mica = micafungin (i.v.), Amb = liposomal amphotericin B. The patient also received prophylactic acyclovir and sulfamethoxazole/trimethoprim (TMP/SMZ) during treatment. c Complete Blood Count (CBC) timeline. ANC (blue), platelet count (green), Hemoglobin (red). Transfusion events (green: platelet transfusion, red: pRBC transfusion) and G-CSF support (blue bar) are integrated in the curve. d Dynamics of Serum Inflammatory Markers. Infectious complications are superimposed above the graph. e Histopathologic analysis of BM biopsies demonstrating severe BM aplasia 1 month after CAR T-cell transfusion (Day 32, upper panel) and evidence of recovering hematopoiesis following autologous stem cell transfer (Autopsy, lower panel). Immunohistochemical staining for myeloperoxidase (= MPO) highlighting strong activation of myelopoiesis (right panel)
Fig. 2 Radiographic evidence of partial response to Axi-cel after 36 days. Contrast-enhanced CT abdomen (axial view) displaying pleural manifestations before (a) and after (b) CAR T-cell treatment. Involved paraaortic lymph nodes (red arrows) demonstrate an interval decrease in size (c-d, e-f). The inset of panel F depicts splenic hypodensities consistent with necrosis of tumor tissue secondary to immune therapy and a reduction of splenomegaly. G Graphical depiction of response over time. Tumor extent was quantified as the sum of the product of perpendicular diameters according to Lugano criteria over 3 time points and is graphed on the y-axis. H Timeline of LDH levels (U/l). The increase in LDH levels at day 25 correlated with the gastrointestinal toxicity and liver dysfunction
Fig. 3 Multi-organ toxicity secondary to CD19-directed CAR T-cell therapy. a Contrast-enhanced CT abdomen demonstrating a non-inflamed baseline state of GI mucosal tissue prior to CAR T therapy. b Panmural swelling of the sigma (left panel), ascending colon (middle panel), and stomach. c Non-pathologic CT of the brain. d Axial FLAIR-weighted (left), T1-weighted contrast-enhanced (middle), and diffusion-weighted (right) MRI displaying no evidence of cerebral edema, white matter lesions, diffusion restriction, microbleeds, meningeal enhancement or contrast enhancing lesions. e High-resolution CT thorax with bilateral fungal infiltrates observing the typical halo configuration 6 weeks prior to CAR T-cell transfusion. f On day − 3 the right-sided infiltrates have decreased in size. The left lung is collapsed due to malignant pleural effusion. g Lung parenchyma exhibiting an infiltration of non-dimorphic blastoconidial morphology consistent with Candida glabrata. h PAS staining of a lung specimen highlights septated hiphae and acute-angle branching, features consistent of with aspergillus infection
During lymphodepletion the patient developed an upper respiratory infection, presenting with a non-productive cough and a sputum culture positive for Bordetella bronchiseptica, which resolved clinically after antibiotic treatment with piperacillin/tazobactam. On day 7, the patient developed fever with a stable cardiopulmonary function and concomitant IL-6 rise (Fig. 1d), which was classified as CRS grade I according to ASTCT consensus grading [7] in the absence of positive blood cultures and other foci. Due to persistent fever refractory to antipyretic treatment, four total doses of tocilizumab (8 mg/kg) were applied over 36 h. Starting on day 9, the patient deteriorated neurologically with a depressed state of consciousness prompting the diagnosis of grade IV ICANS. The patient was transferred to the neurological ICU, and high-dose corticosteroids (methylprednisolone 1000 mg daily) were initiated. CSF-analysis displayed subtle pleocytosis, but revealed no signs of CNS infection (viral, bacterial and fungal) or meningeal involvement of the DLBCL. CT and MR imaging of the brain exhibited none of the pathological findings reported for ICANS [8] or CNS infection [9](Fig. 3c-d). After 5 days of high-dose methylprednisolone, the patient’s neurological status slowly improved, and corticosteroids could be tapered.
Partial response to Axicabtagene-Ciloleucel after 36 days according to Lugano criteria
While the patient’s initial clinical course was fraught with complications, CT staging performed at day 36 demonstrated a partial response to CAR T-cell therapy according to Lugano and Lyric criteria (Fig. 2a-g). This was particularly evident for the pleural manifestations of the underlying DLBCL, which was accompanied by an interval decrease in pleural effusions and subjective dyspnea (Fig. 2a-b). Multiple nodal sites including paraaortic (Fig. 2c-d) and parailiac lymph nodes (Fig. 2e-f) exhibited significant regression of tumor size (Fig. 2g). Moreover, the patient displayed splenic hypodensities consistent with either tumor tissue necrosis or infection-associated inflammatory changes (inset, Fig. 2f). These CT-morphologic findings were accompanied by a decrease of LDH levels (Fig. 2h).
Prolonged cytopenia lead to the development of severe neutropenic colitis and fatal fungal pneumonia
The patient presented with significant myelotoxicity and sustained transfusion dependency after CAR T-cell administration (Fig. 1c). The overall duration of profound neutropenia – defined as an ANC < 100/μl [10] – was 52 days. Because of the severity of ICANS, the clinicians chose to hold G-CSF during this time period due to concerns for risk of worsening toxicity [11].
While receiving broad anti-infectives (acyclovir, TMP/SMZ, posaconazole, meropenem), the patient developed breakthrough septic shock on day 24. He exhibited fever (39.5 °C), hypotension (70/30 mmHg), tachycardia (160/min), as well as lactic acidosis (lactate: 10.7 mmol/l). The patient was non-conversant, non-oriented, and was not able to localize symptoms. However, he had described epigastric tenderness and subtle changes in stool consistency and frequency on the previous day. As a result, abdominal CT imaging was obtained, which displayed severe pancolitis, as evidenced by pronounced mucosal thickening with edematous changes ranging from the ascending colon to the rectum (Fig. 3a-b). Labs were notable for an acute spike of serum inflammatory parameters (Il-6 > 500.000 pg/ml, CRP 5.7 mg/dl, Procalcitonin 11.2 ng/ml, Fig. 1d). Following ICU transfer, high-dose vasopressor support with norepinephrine was initiated together with volume resuscitation to maintain organ perfusion. Due to progressive loss of consciousness the patient was intubated and mechanically ventilated. To control the proinflammatory state, extracorporeal cytokine absorption (Cytosorb®) was performed, which resulted in a decrease of soluble inflammatory markers in the subsequent days. Arterial blood cultures were positive for vancomycin-resistant enterococci (VRE), and the antibiotic treatment was escalated to include linezolid along with meropenem (Fig. 1b). The ICU team transitioned antifungal prophylaxis from posaconazole to an echinocandine (micafungin 50 mg IV) due to ECG changes and concerns for drug interactions on day 24. Though he remained in critical condition, in the coming weeks his clinical condition stabilized and both the catecholamine rate and volume support could be reduced. To determine the origin of sustained myelosuppression, a bone marrow biopsy was obtained, which depicted a hypocellular marrow and severe aplasia affecting all hematopoietic lineages (Fig. 1e). On days 41 and 49, surveillance blood cultures were positive for Candida glabrata, a commensal fungal organism of human mucosal tissues [12] harboring an intrinsic azole resistance [13]. Susceptibility testing confirmed the azole-resistance of C. glabrata isolates. The antimycotic therapy was escalated from micafungin to liposomal amphotericin B. C. glabrata likely disseminated to the bloodstream secondary to the described gastrointestinal toxicity and was previously discovered on rectal swab (Fig. 1b) and fecal culture (day − 51).
Due to sustained neutropenia, BM aplasia and the availability of a suitable apheresis product, the CAR T-cell Taskforce proceeded with a stem cell boost of previously collected autologous CD34+ cells (3,1 × 106 cells) on day 46. The combination of a sudden rise in serum inflammatory markers and a strongly positive serum galactomannan (GM) assay on day 49 prompted diagnostic bronchoscopy, which revealed a diffuse infiltrate of alveolar and peri-bronchial tissue by Aspergillus fumigatus, consistent with fulminant invasive fungal pneumonia. Over the next week, the patient became increasingly hemodynamically unstable with poor peripheral oxygenation. Repeat bronchoscopy with bronchial lavage was positive for A. fumigatus and C. glabrata. After 50 days of G-CSF refractory aplasia, the autologous stem cells slowly engrafted leading to neutrophil recovery. However, this likely exacerbated the local inflammatory reaction in the lung, contributing to rapid deterioration of his respiratory status. Despite extensive supportive measures, the patient died on day 58 after CAR T-cell transfusion. Cause of death was confirmed by autopsy as invasive fungal pneumonia with multi-organ septic spread. Post-mortem examination revealed Candida spores in intestinal, colonic and rectal tissue. Of note, histopathologic BM analysis revealed signs of burgeoning hematopoietic regeneration (Fig. 1e).
Discussion and conclusions
Recent studies have shed light on the high incidence of prolonged and profound neutropenia after adoptive immunotherapy with CD19-specific CAR T-cells [1–3]. Clinical sequalae include severe infectious complications, which have emerged as the number one cause of long-term non-relapse mortality after CAR T-cell therapy [14]. In a seminal study, Hill and colleagues demonstrate that infectious complications are common with a cumulative incidence of 23% in the first 28 days after CAR T-cell transfusion and 14% between days 29–90. While bacterial infections were most common in the first month, viral infections – especially respiratory viruses – predominated after day 29, likely as a result of an impaired adaptive immune response due to B-cell aplasia [15]. Overall, most infections were mild to moderate and fatal infections were rare. Invasive mold infections were uncommon, ranging from 1 to 7% in CAR T-cell recipients [15–17]. In multivariate analyses, the use of systemic corticosteroids for the management of CRS or ICANS has emerged as a major risk factor of infection [18]. Certain inflammatory signatures – such as the “double peaks of IL-6” pattern observed in our patient – have been shown to confer an especially high risk of life-threatening infection [19].
This case highlights the combination of factors that precipitate a high risk of infectious complications in a CAR T-cell patient. First, the heavily pre-treated patient displayed B-cell aplasia and a diminished hematopoietic reserve (e.g. trilineage cytopenia) prior to lymphodepletion. Second, the patient developed classic complications of CAR T-cell therapy such as CRS and severe and prolonged ICANS, reflecting a pro-inflammatory state that represents an important risk factor for developing infections in CAR T-cell patients [16]. The subsequent application of high-dose corticosteroids impaired both innate and adaptive immunity [20]. Third, pancytopenia was profound, prolonged and not able to be reverted by growth factor support. Fourth, the patient had a history of infectious complications, including a course of fungal pneumonia 6 weeks prior to lymphodepletion, likely flaring up in the setting of the above three factors.
Our patient developed severe septic shock secondary to neutropenic colitis on day 24, highlighting the risk of a watch-and-wait approach to prolonged neutropenia after CAR T-cell therapy. A two-pronged approach to management appears prescient. On the one hand, measures to propagate hematopoietic recovery should be exhausted (causal therapy). This can range from G-CSF stimulation, to a trial of pulse-dose corticosteroids or anti-cytokine therapy (e.g. Anakinra, Tocilizumab), to a stem cell boost as a last resort in lymphoma patients who have undergone prior autologous stem cell transplantation. On the other hand, clinicians should be at high alert for infectious complications and adapt their infection surveillance and anti-infective prophylactic strategies accordingly. For example, therapeutic drug monitoring of posaconazole and meropenem levels may have revealed subtherapeutic dosing of these anti-infective agents in this patient [21]. The role of antifungal prophylaxis in the CAR T-cell patient remains inconclusive. Adequately powered studies addressing the duration of neutropenia after CAR T-cell therapy, and potential clinical determinants of invasive fungal infections, will be critical to gauge the benefit of antifungal prophylaxis in this patient collective.
Candida species are a leading cause of fungus-associated morbidity and mortality in severely immunocompromised patients [21]. On day 41, this patient developed breakthrough C. glabrata Candidemia on micafungin, in the setting of both underlying colonization and neutropenic colitis. A recent report implicated the gastrointestinal tract as major source of echinocandin drug resistance in a murine model of C. glabrata colonization and systemic dissemination [22]. Of note, breakthrough Candida infections on micafungin may occur at the employed dose level (50 mg/day IV), suggesting that this dose may have been inadequate to prevent subsequent Candidemia [23]. Though cases of C. glabrata colitis are extremely rare [24], an opportunistic infection could not be ruled out given that C. glabrata infiltrates were discovered in enteral and colonic mucosal tissue on post-mortem examination. Importantly, the patients’ clinical status deteriorated only after the stem cell boost resulted in signs of hematopoietic recovery. The paradoxical worsening of the pulmonary A. fumigatus infection is consistent with immune reconstitution inflammatory syndrome (IRIS), which has been previously described for HIV/AIDS [25] and for severely neutropenic patients with IPA [26]. In conclusion, this case emphasizes that infectious complications secondary to prolonged cytopenia influence non-relapse mortality after CAR T-cell therapy.
Abbreviations
ALCAbsolute Lymphocyte Count
ANCAbsolute Neutrophil Count
BMBone Marrow
CARChimeric antigen receptor
CBCComplete Blood Count
CRSCytokine release syndrome
CTCAECommon Terminology Criteria for Adverse Events
DLBCLDiffuse large B-cell lymphoma
FFPFresh frozen plasma
FLAIRFluid-attenuated inversion recovery
Flu/CyFludarabine/Cyclophosphamide
G-CSFGranulocyte colony stimulating factor
GIGastrointestinal
GMGalactomannan
HSPCsHematopoietic stem and progenitor cells
ICANSImmune effector cell-associated neurotoxicity syndrome
ICE-scoreImmune Effector Cell-associated Encephalopathy score
ICUIntensive care unit
IPAInvasive pulmonary aspergillosis
LDHLactate Dehydrogenase
LYRICLymphoma response to immunomodulatory therapy criteria
MDRDModification of Diet in Renal Disease
MPOMyeloperoxidase
PASPeriodic acid-Schiff
PBSCPeripheral Blood Stem Cell
VREVancomycin-resistant Enterococcus
WBCWhite Blood Count
Publisher’s Note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
Acknowledgements
Not applicable.
Authors’ contributions
The original manuscript was written by KR. KR and WGK prepared the figures. MR performed the histological examination of the bone marrow. MS reviewed and edited the manuscript. The other authors (VB1, VB2, CS, PK, FS, KD, LvB, JS, OW, MD, MvBB) contributed to patient management and participated in drafting and editing the manuscript. All authors read and approved the final manuscript.
Funding
Not applicable. Open Access funding enabled and organized by Projekt DEAL.
Availability of data and materials
The authors did not use any database, software, or tools for the writing of this manuscript.
Ethics approval and consent to participate
The authors obtained consent from the deceased patient’s next-of-kin to participate.
Consent for publication
Written informed consent was obtained from the patient’s next-of-kin for publication of this Case report and any accompanying images. A copy of the written consent is available for review by the Editor of this journal.
Competing interests
The authors declare that they have no competing interests related with this case report. | Fatal | ReactionOutcome | CC BY | 33509115 | 18,947,434 | 2021-01-28 |
What was the outcome of reaction 'Colitis'? | Severe Candida glabrata pancolitis and fatal Aspergillus fumigatus pulmonary infection in the setting of bone marrow aplasia after CD19-directed CAR T-cell therapy - a case report.
BACKGROUND
Prolonged myelosuppression following CD19-directed CAR T-cell transfusion represents an important, yet underreported, adverse event. The resulting neutropenia and multifactorial immunosuppression can facilitate severe infectious complications.
METHODS
We describe the clinical course of a 59-year-old patient with relapsed/refractory DLBCL who received Axicabtagene-Ciloleucel (Axi-cel). The patient developed ASTCT grade I CRS and grade IV ICANS, necessitating admission to the neurological ICU and prolonged application of high-dose corticosteroids and other immunosuppressive agents. Importantly, neutropenia was profound (ANC < 100/μl), G-CSF-refractory, and prolonged, lasting more than 50 days. The patient developed severe septic shock 3 weeks after CAR transfusion while receiving anti-fungal prophylaxis with micafungin. His clinical status stabilized with broad anti-infective treatment and intensive supportive measures. An autologous stem cell backup was employed on day 46 to support hematopoietic recovery. Although the counts of the patient eventually started to recover, he developed an invasive pulmonary aspergillosis, which ultimately lead to respiratory failure and death. Postmortem examination revealed signs of Candida glabrata pancolitis.
CONCLUSIONS
This case highlights the increased risk for fatal infectious complications in patients who present with profound and prolonged cytopenia after CAR T-cell therapy. We describe a rare case of C. glabrata pancolitis associated with multifactorial immunosuppression. Although our patient succumbed to a fatal fungal infection, autologous stem cell boost was able to spur hematopoiesis and may represent an important therapeutic strategy for DLBCL patients with CAR T-cell associated bone marrow aplasia who have underwent prior stem cell harvest.
Background
When CD19-directed Chimeric Antigen Receptor (CAR) T-cell therapies were first introduced into the clinical setting, a set of distinctive side effects were observed, including Cytokine Release Syndrome (CRS) and immune effector cell-associated neurotoxicity syndrome (ICANS). As these treatments transition from large clinical trials to real-world implementation, new nuances of the side effect spectrum have emerged. This includes the observation that patients can present not only with grade 3–4 cytopenia (CTCAE v5.0), but also a syndrome of persistent cytopenia after CAR T-cell transfusion [1, 2]. Hematologic toxicity is common with one study demonstrating that neutropenia, thrombocytopenia and anemia occur in 94, 80 and 51% of patients respectively [3]. Risk factors for hematotoxicity include CRS grade, baseline cytopenia, and prior allogeneic stem cell transplantation within the last year [2, 3]. The fact that baseline hematopoietic reserve contributes to cytopenia in CAR T-cell patients may explain the variability in the incidence of hematoxicity in the real-world setting compared to the large registration trials, which set stringent hematologic exclusion criteria [4, 5]. The clinical utility of therapeutic rescue strategies that mitigate the risk of infectious complications secondary to long-term bone marrow (BM) aplasia, such as early autologous stem cell boost or Eltrombopag, remains unknown. Moreover, the relative paucity of reports concerning severe and life-threatening infections in the reported CD19-directed CAR T-cell trials necessitates the presentation of distinctive clinical courses that underline the risks of persistent cytopenia after CAR T-cell therapy in a real-world setting.
Case presentation
The 59-year-old male patient was initially diagnosed with stage IIIA follicular lymphoma in January 2018, which transformed to germinal center B-cell like DLBCL in October of the same year. Refractory to multiple cycles of Rituximab-based immunochemotherapy (Fig. 1a), the patient underwent leukapheresis for CAR T-cell therapy in April 2019. The patient experienced significant lymphoma progression during the manufacturing process of Axicabtagene ciloleucel (Axi-cel), manifesting itself in the form of malignant pleural effusions and progressive lymphadenopathy (Fig. 2a,c,e). In the six-week period between leukapheresis and lymphodepletion, the patient remained severely neutropenic after R-CHOP and developed possible invasive fungal disease (IFD) [6] (Fig. 3e) as well as E. coli septicemia secondary to a urinary tract infection. These infections were treated successfully with liposomal amphotericin B and piperacillin/tazobactam. Prior to lymphodepletion (D-5), the patient presented with an ECOG performance status of 1, intact renal and liver function, while observing residually depressed blood counts (WBC 1270/μl, ANC 700/μl, ALC 390/μl, Hemoglobin 7.2 g/dl, Platelets 20 G/l). BM histopathology showed a hypocellular marrow with no evidence of lymphoma infiltration. Analysis of lymphocyte subpopulations demonstrated severe B-cell aplasia and decreased absolute CD4+ (84/μl) and CD8+ (271/μl) counts. His anti-infective prophylaxis consisted of a combination of acyclovir, sulfamethoxazole/trimethoprim (TMP/SMZ), and posaconazole. The fludarabine/cyclophosphamide lympho-preparative regimen was applied on days − 5 to − 3 according to the provider’s protocol, followed by CAR T-cell transfusion on day 0.
Fig. 1 Overview of CAR T-cell mediated hematotoxicity and infectious complications. a Treatment course prior to CAR T-cell therapy. b Timeline of infectious complications during CAR T-cell treatment course. Positive microbiologic culture results are underlined. Bottom: Overview of utilized anti-infectives with the respective bars displaying the length of treatment. P/T = piperacillin/tazobactam, Ami = amikacin, Mero = meropenem, Vanco = vancomycin, Line = linezolid, Posa = posaconazole (p.o.), Mica = micafungin (i.v.), Amb = liposomal amphotericin B. The patient also received prophylactic acyclovir and sulfamethoxazole/trimethoprim (TMP/SMZ) during treatment. c Complete Blood Count (CBC) timeline. ANC (blue), platelet count (green), Hemoglobin (red). Transfusion events (green: platelet transfusion, red: pRBC transfusion) and G-CSF support (blue bar) are integrated in the curve. d Dynamics of Serum Inflammatory Markers. Infectious complications are superimposed above the graph. e Histopathologic analysis of BM biopsies demonstrating severe BM aplasia 1 month after CAR T-cell transfusion (Day 32, upper panel) and evidence of recovering hematopoiesis following autologous stem cell transfer (Autopsy, lower panel). Immunohistochemical staining for myeloperoxidase (= MPO) highlighting strong activation of myelopoiesis (right panel)
Fig. 2 Radiographic evidence of partial response to Axi-cel after 36 days. Contrast-enhanced CT abdomen (axial view) displaying pleural manifestations before (a) and after (b) CAR T-cell treatment. Involved paraaortic lymph nodes (red arrows) demonstrate an interval decrease in size (c-d, e-f). The inset of panel F depicts splenic hypodensities consistent with necrosis of tumor tissue secondary to immune therapy and a reduction of splenomegaly. G Graphical depiction of response over time. Tumor extent was quantified as the sum of the product of perpendicular diameters according to Lugano criteria over 3 time points and is graphed on the y-axis. H Timeline of LDH levels (U/l). The increase in LDH levels at day 25 correlated with the gastrointestinal toxicity and liver dysfunction
Fig. 3 Multi-organ toxicity secondary to CD19-directed CAR T-cell therapy. a Contrast-enhanced CT abdomen demonstrating a non-inflamed baseline state of GI mucosal tissue prior to CAR T therapy. b Panmural swelling of the sigma (left panel), ascending colon (middle panel), and stomach. c Non-pathologic CT of the brain. d Axial FLAIR-weighted (left), T1-weighted contrast-enhanced (middle), and diffusion-weighted (right) MRI displaying no evidence of cerebral edema, white matter lesions, diffusion restriction, microbleeds, meningeal enhancement or contrast enhancing lesions. e High-resolution CT thorax with bilateral fungal infiltrates observing the typical halo configuration 6 weeks prior to CAR T-cell transfusion. f On day − 3 the right-sided infiltrates have decreased in size. The left lung is collapsed due to malignant pleural effusion. g Lung parenchyma exhibiting an infiltration of non-dimorphic blastoconidial morphology consistent with Candida glabrata. h PAS staining of a lung specimen highlights septated hiphae and acute-angle branching, features consistent of with aspergillus infection
During lymphodepletion the patient developed an upper respiratory infection, presenting with a non-productive cough and a sputum culture positive for Bordetella bronchiseptica, which resolved clinically after antibiotic treatment with piperacillin/tazobactam. On day 7, the patient developed fever with a stable cardiopulmonary function and concomitant IL-6 rise (Fig. 1d), which was classified as CRS grade I according to ASTCT consensus grading [7] in the absence of positive blood cultures and other foci. Due to persistent fever refractory to antipyretic treatment, four total doses of tocilizumab (8 mg/kg) were applied over 36 h. Starting on day 9, the patient deteriorated neurologically with a depressed state of consciousness prompting the diagnosis of grade IV ICANS. The patient was transferred to the neurological ICU, and high-dose corticosteroids (methylprednisolone 1000 mg daily) were initiated. CSF-analysis displayed subtle pleocytosis, but revealed no signs of CNS infection (viral, bacterial and fungal) or meningeal involvement of the DLBCL. CT and MR imaging of the brain exhibited none of the pathological findings reported for ICANS [8] or CNS infection [9](Fig. 3c-d). After 5 days of high-dose methylprednisolone, the patient’s neurological status slowly improved, and corticosteroids could be tapered.
Partial response to Axicabtagene-Ciloleucel after 36 days according to Lugano criteria
While the patient’s initial clinical course was fraught with complications, CT staging performed at day 36 demonstrated a partial response to CAR T-cell therapy according to Lugano and Lyric criteria (Fig. 2a-g). This was particularly evident for the pleural manifestations of the underlying DLBCL, which was accompanied by an interval decrease in pleural effusions and subjective dyspnea (Fig. 2a-b). Multiple nodal sites including paraaortic (Fig. 2c-d) and parailiac lymph nodes (Fig. 2e-f) exhibited significant regression of tumor size (Fig. 2g). Moreover, the patient displayed splenic hypodensities consistent with either tumor tissue necrosis or infection-associated inflammatory changes (inset, Fig. 2f). These CT-morphologic findings were accompanied by a decrease of LDH levels (Fig. 2h).
Prolonged cytopenia lead to the development of severe neutropenic colitis and fatal fungal pneumonia
The patient presented with significant myelotoxicity and sustained transfusion dependency after CAR T-cell administration (Fig. 1c). The overall duration of profound neutropenia – defined as an ANC < 100/μl [10] – was 52 days. Because of the severity of ICANS, the clinicians chose to hold G-CSF during this time period due to concerns for risk of worsening toxicity [11].
While receiving broad anti-infectives (acyclovir, TMP/SMZ, posaconazole, meropenem), the patient developed breakthrough septic shock on day 24. He exhibited fever (39.5 °C), hypotension (70/30 mmHg), tachycardia (160/min), as well as lactic acidosis (lactate: 10.7 mmol/l). The patient was non-conversant, non-oriented, and was not able to localize symptoms. However, he had described epigastric tenderness and subtle changes in stool consistency and frequency on the previous day. As a result, abdominal CT imaging was obtained, which displayed severe pancolitis, as evidenced by pronounced mucosal thickening with edematous changes ranging from the ascending colon to the rectum (Fig. 3a-b). Labs were notable for an acute spike of serum inflammatory parameters (Il-6 > 500.000 pg/ml, CRP 5.7 mg/dl, Procalcitonin 11.2 ng/ml, Fig. 1d). Following ICU transfer, high-dose vasopressor support with norepinephrine was initiated together with volume resuscitation to maintain organ perfusion. Due to progressive loss of consciousness the patient was intubated and mechanically ventilated. To control the proinflammatory state, extracorporeal cytokine absorption (Cytosorb®) was performed, which resulted in a decrease of soluble inflammatory markers in the subsequent days. Arterial blood cultures were positive for vancomycin-resistant enterococci (VRE), and the antibiotic treatment was escalated to include linezolid along with meropenem (Fig. 1b). The ICU team transitioned antifungal prophylaxis from posaconazole to an echinocandine (micafungin 50 mg IV) due to ECG changes and concerns for drug interactions on day 24. Though he remained in critical condition, in the coming weeks his clinical condition stabilized and both the catecholamine rate and volume support could be reduced. To determine the origin of sustained myelosuppression, a bone marrow biopsy was obtained, which depicted a hypocellular marrow and severe aplasia affecting all hematopoietic lineages (Fig. 1e). On days 41 and 49, surveillance blood cultures were positive for Candida glabrata, a commensal fungal organism of human mucosal tissues [12] harboring an intrinsic azole resistance [13]. Susceptibility testing confirmed the azole-resistance of C. glabrata isolates. The antimycotic therapy was escalated from micafungin to liposomal amphotericin B. C. glabrata likely disseminated to the bloodstream secondary to the described gastrointestinal toxicity and was previously discovered on rectal swab (Fig. 1b) and fecal culture (day − 51).
Due to sustained neutropenia, BM aplasia and the availability of a suitable apheresis product, the CAR T-cell Taskforce proceeded with a stem cell boost of previously collected autologous CD34+ cells (3,1 × 106 cells) on day 46. The combination of a sudden rise in serum inflammatory markers and a strongly positive serum galactomannan (GM) assay on day 49 prompted diagnostic bronchoscopy, which revealed a diffuse infiltrate of alveolar and peri-bronchial tissue by Aspergillus fumigatus, consistent with fulminant invasive fungal pneumonia. Over the next week, the patient became increasingly hemodynamically unstable with poor peripheral oxygenation. Repeat bronchoscopy with bronchial lavage was positive for A. fumigatus and C. glabrata. After 50 days of G-CSF refractory aplasia, the autologous stem cells slowly engrafted leading to neutrophil recovery. However, this likely exacerbated the local inflammatory reaction in the lung, contributing to rapid deterioration of his respiratory status. Despite extensive supportive measures, the patient died on day 58 after CAR T-cell transfusion. Cause of death was confirmed by autopsy as invasive fungal pneumonia with multi-organ septic spread. Post-mortem examination revealed Candida spores in intestinal, colonic and rectal tissue. Of note, histopathologic BM analysis revealed signs of burgeoning hematopoietic regeneration (Fig. 1e).
Discussion and conclusions
Recent studies have shed light on the high incidence of prolonged and profound neutropenia after adoptive immunotherapy with CD19-specific CAR T-cells [1–3]. Clinical sequalae include severe infectious complications, which have emerged as the number one cause of long-term non-relapse mortality after CAR T-cell therapy [14]. In a seminal study, Hill and colleagues demonstrate that infectious complications are common with a cumulative incidence of 23% in the first 28 days after CAR T-cell transfusion and 14% between days 29–90. While bacterial infections were most common in the first month, viral infections – especially respiratory viruses – predominated after day 29, likely as a result of an impaired adaptive immune response due to B-cell aplasia [15]. Overall, most infections were mild to moderate and fatal infections were rare. Invasive mold infections were uncommon, ranging from 1 to 7% in CAR T-cell recipients [15–17]. In multivariate analyses, the use of systemic corticosteroids for the management of CRS or ICANS has emerged as a major risk factor of infection [18]. Certain inflammatory signatures – such as the “double peaks of IL-6” pattern observed in our patient – have been shown to confer an especially high risk of life-threatening infection [19].
This case highlights the combination of factors that precipitate a high risk of infectious complications in a CAR T-cell patient. First, the heavily pre-treated patient displayed B-cell aplasia and a diminished hematopoietic reserve (e.g. trilineage cytopenia) prior to lymphodepletion. Second, the patient developed classic complications of CAR T-cell therapy such as CRS and severe and prolonged ICANS, reflecting a pro-inflammatory state that represents an important risk factor for developing infections in CAR T-cell patients [16]. The subsequent application of high-dose corticosteroids impaired both innate and adaptive immunity [20]. Third, pancytopenia was profound, prolonged and not able to be reverted by growth factor support. Fourth, the patient had a history of infectious complications, including a course of fungal pneumonia 6 weeks prior to lymphodepletion, likely flaring up in the setting of the above three factors.
Our patient developed severe septic shock secondary to neutropenic colitis on day 24, highlighting the risk of a watch-and-wait approach to prolonged neutropenia after CAR T-cell therapy. A two-pronged approach to management appears prescient. On the one hand, measures to propagate hematopoietic recovery should be exhausted (causal therapy). This can range from G-CSF stimulation, to a trial of pulse-dose corticosteroids or anti-cytokine therapy (e.g. Anakinra, Tocilizumab), to a stem cell boost as a last resort in lymphoma patients who have undergone prior autologous stem cell transplantation. On the other hand, clinicians should be at high alert for infectious complications and adapt their infection surveillance and anti-infective prophylactic strategies accordingly. For example, therapeutic drug monitoring of posaconazole and meropenem levels may have revealed subtherapeutic dosing of these anti-infective agents in this patient [21]. The role of antifungal prophylaxis in the CAR T-cell patient remains inconclusive. Adequately powered studies addressing the duration of neutropenia after CAR T-cell therapy, and potential clinical determinants of invasive fungal infections, will be critical to gauge the benefit of antifungal prophylaxis in this patient collective.
Candida species are a leading cause of fungus-associated morbidity and mortality in severely immunocompromised patients [21]. On day 41, this patient developed breakthrough C. glabrata Candidemia on micafungin, in the setting of both underlying colonization and neutropenic colitis. A recent report implicated the gastrointestinal tract as major source of echinocandin drug resistance in a murine model of C. glabrata colonization and systemic dissemination [22]. Of note, breakthrough Candida infections on micafungin may occur at the employed dose level (50 mg/day IV), suggesting that this dose may have been inadequate to prevent subsequent Candidemia [23]. Though cases of C. glabrata colitis are extremely rare [24], an opportunistic infection could not be ruled out given that C. glabrata infiltrates were discovered in enteral and colonic mucosal tissue on post-mortem examination. Importantly, the patients’ clinical status deteriorated only after the stem cell boost resulted in signs of hematopoietic recovery. The paradoxical worsening of the pulmonary A. fumigatus infection is consistent with immune reconstitution inflammatory syndrome (IRIS), which has been previously described for HIV/AIDS [25] and for severely neutropenic patients with IPA [26]. In conclusion, this case emphasizes that infectious complications secondary to prolonged cytopenia influence non-relapse mortality after CAR T-cell therapy.
Abbreviations
ALCAbsolute Lymphocyte Count
ANCAbsolute Neutrophil Count
BMBone Marrow
CARChimeric antigen receptor
CBCComplete Blood Count
CRSCytokine release syndrome
CTCAECommon Terminology Criteria for Adverse Events
DLBCLDiffuse large B-cell lymphoma
FFPFresh frozen plasma
FLAIRFluid-attenuated inversion recovery
Flu/CyFludarabine/Cyclophosphamide
G-CSFGranulocyte colony stimulating factor
GIGastrointestinal
GMGalactomannan
HSPCsHematopoietic stem and progenitor cells
ICANSImmune effector cell-associated neurotoxicity syndrome
ICE-scoreImmune Effector Cell-associated Encephalopathy score
ICUIntensive care unit
IPAInvasive pulmonary aspergillosis
LDHLactate Dehydrogenase
LYRICLymphoma response to immunomodulatory therapy criteria
MDRDModification of Diet in Renal Disease
MPOMyeloperoxidase
PASPeriodic acid-Schiff
PBSCPeripheral Blood Stem Cell
VREVancomycin-resistant Enterococcus
WBCWhite Blood Count
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Acknowledgements
Not applicable.
Authors’ contributions
The original manuscript was written by KR. KR and WGK prepared the figures. MR performed the histological examination of the bone marrow. MS reviewed and edited the manuscript. The other authors (VB1, VB2, CS, PK, FS, KD, LvB, JS, OW, MD, MvBB) contributed to patient management and participated in drafting and editing the manuscript. All authors read and approved the final manuscript.
Funding
Not applicable. Open Access funding enabled and organized by Projekt DEAL.
Availability of data and materials
The authors did not use any database, software, or tools for the writing of this manuscript.
Ethics approval and consent to participate
The authors obtained consent from the deceased patient’s next-of-kin to participate.
Consent for publication
Written informed consent was obtained from the patient’s next-of-kin for publication of this Case report and any accompanying images. A copy of the written consent is available for review by the Editor of this journal.
Competing interests
The authors declare that they have no competing interests related with this case report. | Fatal | ReactionOutcome | CC BY | 33509115 | 18,947,434 | 2021-01-28 |
What was the outcome of reaction 'Escherichia sepsis'? | Severe Candida glabrata pancolitis and fatal Aspergillus fumigatus pulmonary infection in the setting of bone marrow aplasia after CD19-directed CAR T-cell therapy - a case report.
BACKGROUND
Prolonged myelosuppression following CD19-directed CAR T-cell transfusion represents an important, yet underreported, adverse event. The resulting neutropenia and multifactorial immunosuppression can facilitate severe infectious complications.
METHODS
We describe the clinical course of a 59-year-old patient with relapsed/refractory DLBCL who received Axicabtagene-Ciloleucel (Axi-cel). The patient developed ASTCT grade I CRS and grade IV ICANS, necessitating admission to the neurological ICU and prolonged application of high-dose corticosteroids and other immunosuppressive agents. Importantly, neutropenia was profound (ANC < 100/μl), G-CSF-refractory, and prolonged, lasting more than 50 days. The patient developed severe septic shock 3 weeks after CAR transfusion while receiving anti-fungal prophylaxis with micafungin. His clinical status stabilized with broad anti-infective treatment and intensive supportive measures. An autologous stem cell backup was employed on day 46 to support hematopoietic recovery. Although the counts of the patient eventually started to recover, he developed an invasive pulmonary aspergillosis, which ultimately lead to respiratory failure and death. Postmortem examination revealed signs of Candida glabrata pancolitis.
CONCLUSIONS
This case highlights the increased risk for fatal infectious complications in patients who present with profound and prolonged cytopenia after CAR T-cell therapy. We describe a rare case of C. glabrata pancolitis associated with multifactorial immunosuppression. Although our patient succumbed to a fatal fungal infection, autologous stem cell boost was able to spur hematopoiesis and may represent an important therapeutic strategy for DLBCL patients with CAR T-cell associated bone marrow aplasia who have underwent prior stem cell harvest.
Background
When CD19-directed Chimeric Antigen Receptor (CAR) T-cell therapies were first introduced into the clinical setting, a set of distinctive side effects were observed, including Cytokine Release Syndrome (CRS) and immune effector cell-associated neurotoxicity syndrome (ICANS). As these treatments transition from large clinical trials to real-world implementation, new nuances of the side effect spectrum have emerged. This includes the observation that patients can present not only with grade 3–4 cytopenia (CTCAE v5.0), but also a syndrome of persistent cytopenia after CAR T-cell transfusion [1, 2]. Hematologic toxicity is common with one study demonstrating that neutropenia, thrombocytopenia and anemia occur in 94, 80 and 51% of patients respectively [3]. Risk factors for hematotoxicity include CRS grade, baseline cytopenia, and prior allogeneic stem cell transplantation within the last year [2, 3]. The fact that baseline hematopoietic reserve contributes to cytopenia in CAR T-cell patients may explain the variability in the incidence of hematoxicity in the real-world setting compared to the large registration trials, which set stringent hematologic exclusion criteria [4, 5]. The clinical utility of therapeutic rescue strategies that mitigate the risk of infectious complications secondary to long-term bone marrow (BM) aplasia, such as early autologous stem cell boost or Eltrombopag, remains unknown. Moreover, the relative paucity of reports concerning severe and life-threatening infections in the reported CD19-directed CAR T-cell trials necessitates the presentation of distinctive clinical courses that underline the risks of persistent cytopenia after CAR T-cell therapy in a real-world setting.
Case presentation
The 59-year-old male patient was initially diagnosed with stage IIIA follicular lymphoma in January 2018, which transformed to germinal center B-cell like DLBCL in October of the same year. Refractory to multiple cycles of Rituximab-based immunochemotherapy (Fig. 1a), the patient underwent leukapheresis for CAR T-cell therapy in April 2019. The patient experienced significant lymphoma progression during the manufacturing process of Axicabtagene ciloleucel (Axi-cel), manifesting itself in the form of malignant pleural effusions and progressive lymphadenopathy (Fig. 2a,c,e). In the six-week period between leukapheresis and lymphodepletion, the patient remained severely neutropenic after R-CHOP and developed possible invasive fungal disease (IFD) [6] (Fig. 3e) as well as E. coli septicemia secondary to a urinary tract infection. These infections were treated successfully with liposomal amphotericin B and piperacillin/tazobactam. Prior to lymphodepletion (D-5), the patient presented with an ECOG performance status of 1, intact renal and liver function, while observing residually depressed blood counts (WBC 1270/μl, ANC 700/μl, ALC 390/μl, Hemoglobin 7.2 g/dl, Platelets 20 G/l). BM histopathology showed a hypocellular marrow with no evidence of lymphoma infiltration. Analysis of lymphocyte subpopulations demonstrated severe B-cell aplasia and decreased absolute CD4+ (84/μl) and CD8+ (271/μl) counts. His anti-infective prophylaxis consisted of a combination of acyclovir, sulfamethoxazole/trimethoprim (TMP/SMZ), and posaconazole. The fludarabine/cyclophosphamide lympho-preparative regimen was applied on days − 5 to − 3 according to the provider’s protocol, followed by CAR T-cell transfusion on day 0.
Fig. 1 Overview of CAR T-cell mediated hematotoxicity and infectious complications. a Treatment course prior to CAR T-cell therapy. b Timeline of infectious complications during CAR T-cell treatment course. Positive microbiologic culture results are underlined. Bottom: Overview of utilized anti-infectives with the respective bars displaying the length of treatment. P/T = piperacillin/tazobactam, Ami = amikacin, Mero = meropenem, Vanco = vancomycin, Line = linezolid, Posa = posaconazole (p.o.), Mica = micafungin (i.v.), Amb = liposomal amphotericin B. The patient also received prophylactic acyclovir and sulfamethoxazole/trimethoprim (TMP/SMZ) during treatment. c Complete Blood Count (CBC) timeline. ANC (blue), platelet count (green), Hemoglobin (red). Transfusion events (green: platelet transfusion, red: pRBC transfusion) and G-CSF support (blue bar) are integrated in the curve. d Dynamics of Serum Inflammatory Markers. Infectious complications are superimposed above the graph. e Histopathologic analysis of BM biopsies demonstrating severe BM aplasia 1 month after CAR T-cell transfusion (Day 32, upper panel) and evidence of recovering hematopoiesis following autologous stem cell transfer (Autopsy, lower panel). Immunohistochemical staining for myeloperoxidase (= MPO) highlighting strong activation of myelopoiesis (right panel)
Fig. 2 Radiographic evidence of partial response to Axi-cel after 36 days. Contrast-enhanced CT abdomen (axial view) displaying pleural manifestations before (a) and after (b) CAR T-cell treatment. Involved paraaortic lymph nodes (red arrows) demonstrate an interval decrease in size (c-d, e-f). The inset of panel F depicts splenic hypodensities consistent with necrosis of tumor tissue secondary to immune therapy and a reduction of splenomegaly. G Graphical depiction of response over time. Tumor extent was quantified as the sum of the product of perpendicular diameters according to Lugano criteria over 3 time points and is graphed on the y-axis. H Timeline of LDH levels (U/l). The increase in LDH levels at day 25 correlated with the gastrointestinal toxicity and liver dysfunction
Fig. 3 Multi-organ toxicity secondary to CD19-directed CAR T-cell therapy. a Contrast-enhanced CT abdomen demonstrating a non-inflamed baseline state of GI mucosal tissue prior to CAR T therapy. b Panmural swelling of the sigma (left panel), ascending colon (middle panel), and stomach. c Non-pathologic CT of the brain. d Axial FLAIR-weighted (left), T1-weighted contrast-enhanced (middle), and diffusion-weighted (right) MRI displaying no evidence of cerebral edema, white matter lesions, diffusion restriction, microbleeds, meningeal enhancement or contrast enhancing lesions. e High-resolution CT thorax with bilateral fungal infiltrates observing the typical halo configuration 6 weeks prior to CAR T-cell transfusion. f On day − 3 the right-sided infiltrates have decreased in size. The left lung is collapsed due to malignant pleural effusion. g Lung parenchyma exhibiting an infiltration of non-dimorphic blastoconidial morphology consistent with Candida glabrata. h PAS staining of a lung specimen highlights septated hiphae and acute-angle branching, features consistent of with aspergillus infection
During lymphodepletion the patient developed an upper respiratory infection, presenting with a non-productive cough and a sputum culture positive for Bordetella bronchiseptica, which resolved clinically after antibiotic treatment with piperacillin/tazobactam. On day 7, the patient developed fever with a stable cardiopulmonary function and concomitant IL-6 rise (Fig. 1d), which was classified as CRS grade I according to ASTCT consensus grading [7] in the absence of positive blood cultures and other foci. Due to persistent fever refractory to antipyretic treatment, four total doses of tocilizumab (8 mg/kg) were applied over 36 h. Starting on day 9, the patient deteriorated neurologically with a depressed state of consciousness prompting the diagnosis of grade IV ICANS. The patient was transferred to the neurological ICU, and high-dose corticosteroids (methylprednisolone 1000 mg daily) were initiated. CSF-analysis displayed subtle pleocytosis, but revealed no signs of CNS infection (viral, bacterial and fungal) or meningeal involvement of the DLBCL. CT and MR imaging of the brain exhibited none of the pathological findings reported for ICANS [8] or CNS infection [9](Fig. 3c-d). After 5 days of high-dose methylprednisolone, the patient’s neurological status slowly improved, and corticosteroids could be tapered.
Partial response to Axicabtagene-Ciloleucel after 36 days according to Lugano criteria
While the patient’s initial clinical course was fraught with complications, CT staging performed at day 36 demonstrated a partial response to CAR T-cell therapy according to Lugano and Lyric criteria (Fig. 2a-g). This was particularly evident for the pleural manifestations of the underlying DLBCL, which was accompanied by an interval decrease in pleural effusions and subjective dyspnea (Fig. 2a-b). Multiple nodal sites including paraaortic (Fig. 2c-d) and parailiac lymph nodes (Fig. 2e-f) exhibited significant regression of tumor size (Fig. 2g). Moreover, the patient displayed splenic hypodensities consistent with either tumor tissue necrosis or infection-associated inflammatory changes (inset, Fig. 2f). These CT-morphologic findings were accompanied by a decrease of LDH levels (Fig. 2h).
Prolonged cytopenia lead to the development of severe neutropenic colitis and fatal fungal pneumonia
The patient presented with significant myelotoxicity and sustained transfusion dependency after CAR T-cell administration (Fig. 1c). The overall duration of profound neutropenia – defined as an ANC < 100/μl [10] – was 52 days. Because of the severity of ICANS, the clinicians chose to hold G-CSF during this time period due to concerns for risk of worsening toxicity [11].
While receiving broad anti-infectives (acyclovir, TMP/SMZ, posaconazole, meropenem), the patient developed breakthrough septic shock on day 24. He exhibited fever (39.5 °C), hypotension (70/30 mmHg), tachycardia (160/min), as well as lactic acidosis (lactate: 10.7 mmol/l). The patient was non-conversant, non-oriented, and was not able to localize symptoms. However, he had described epigastric tenderness and subtle changes in stool consistency and frequency on the previous day. As a result, abdominal CT imaging was obtained, which displayed severe pancolitis, as evidenced by pronounced mucosal thickening with edematous changes ranging from the ascending colon to the rectum (Fig. 3a-b). Labs were notable for an acute spike of serum inflammatory parameters (Il-6 > 500.000 pg/ml, CRP 5.7 mg/dl, Procalcitonin 11.2 ng/ml, Fig. 1d). Following ICU transfer, high-dose vasopressor support with norepinephrine was initiated together with volume resuscitation to maintain organ perfusion. Due to progressive loss of consciousness the patient was intubated and mechanically ventilated. To control the proinflammatory state, extracorporeal cytokine absorption (Cytosorb®) was performed, which resulted in a decrease of soluble inflammatory markers in the subsequent days. Arterial blood cultures were positive for vancomycin-resistant enterococci (VRE), and the antibiotic treatment was escalated to include linezolid along with meropenem (Fig. 1b). The ICU team transitioned antifungal prophylaxis from posaconazole to an echinocandine (micafungin 50 mg IV) due to ECG changes and concerns for drug interactions on day 24. Though he remained in critical condition, in the coming weeks his clinical condition stabilized and both the catecholamine rate and volume support could be reduced. To determine the origin of sustained myelosuppression, a bone marrow biopsy was obtained, which depicted a hypocellular marrow and severe aplasia affecting all hematopoietic lineages (Fig. 1e). On days 41 and 49, surveillance blood cultures were positive for Candida glabrata, a commensal fungal organism of human mucosal tissues [12] harboring an intrinsic azole resistance [13]. Susceptibility testing confirmed the azole-resistance of C. glabrata isolates. The antimycotic therapy was escalated from micafungin to liposomal amphotericin B. C. glabrata likely disseminated to the bloodstream secondary to the described gastrointestinal toxicity and was previously discovered on rectal swab (Fig. 1b) and fecal culture (day − 51).
Due to sustained neutropenia, BM aplasia and the availability of a suitable apheresis product, the CAR T-cell Taskforce proceeded with a stem cell boost of previously collected autologous CD34+ cells (3,1 × 106 cells) on day 46. The combination of a sudden rise in serum inflammatory markers and a strongly positive serum galactomannan (GM) assay on day 49 prompted diagnostic bronchoscopy, which revealed a diffuse infiltrate of alveolar and peri-bronchial tissue by Aspergillus fumigatus, consistent with fulminant invasive fungal pneumonia. Over the next week, the patient became increasingly hemodynamically unstable with poor peripheral oxygenation. Repeat bronchoscopy with bronchial lavage was positive for A. fumigatus and C. glabrata. After 50 days of G-CSF refractory aplasia, the autologous stem cells slowly engrafted leading to neutrophil recovery. However, this likely exacerbated the local inflammatory reaction in the lung, contributing to rapid deterioration of his respiratory status. Despite extensive supportive measures, the patient died on day 58 after CAR T-cell transfusion. Cause of death was confirmed by autopsy as invasive fungal pneumonia with multi-organ septic spread. Post-mortem examination revealed Candida spores in intestinal, colonic and rectal tissue. Of note, histopathologic BM analysis revealed signs of burgeoning hematopoietic regeneration (Fig. 1e).
Discussion and conclusions
Recent studies have shed light on the high incidence of prolonged and profound neutropenia after adoptive immunotherapy with CD19-specific CAR T-cells [1–3]. Clinical sequalae include severe infectious complications, which have emerged as the number one cause of long-term non-relapse mortality after CAR T-cell therapy [14]. In a seminal study, Hill and colleagues demonstrate that infectious complications are common with a cumulative incidence of 23% in the first 28 days after CAR T-cell transfusion and 14% between days 29–90. While bacterial infections were most common in the first month, viral infections – especially respiratory viruses – predominated after day 29, likely as a result of an impaired adaptive immune response due to B-cell aplasia [15]. Overall, most infections were mild to moderate and fatal infections were rare. Invasive mold infections were uncommon, ranging from 1 to 7% in CAR T-cell recipients [15–17]. In multivariate analyses, the use of systemic corticosteroids for the management of CRS or ICANS has emerged as a major risk factor of infection [18]. Certain inflammatory signatures – such as the “double peaks of IL-6” pattern observed in our patient – have been shown to confer an especially high risk of life-threatening infection [19].
This case highlights the combination of factors that precipitate a high risk of infectious complications in a CAR T-cell patient. First, the heavily pre-treated patient displayed B-cell aplasia and a diminished hematopoietic reserve (e.g. trilineage cytopenia) prior to lymphodepletion. Second, the patient developed classic complications of CAR T-cell therapy such as CRS and severe and prolonged ICANS, reflecting a pro-inflammatory state that represents an important risk factor for developing infections in CAR T-cell patients [16]. The subsequent application of high-dose corticosteroids impaired both innate and adaptive immunity [20]. Third, pancytopenia was profound, prolonged and not able to be reverted by growth factor support. Fourth, the patient had a history of infectious complications, including a course of fungal pneumonia 6 weeks prior to lymphodepletion, likely flaring up in the setting of the above three factors.
Our patient developed severe septic shock secondary to neutropenic colitis on day 24, highlighting the risk of a watch-and-wait approach to prolonged neutropenia after CAR T-cell therapy. A two-pronged approach to management appears prescient. On the one hand, measures to propagate hematopoietic recovery should be exhausted (causal therapy). This can range from G-CSF stimulation, to a trial of pulse-dose corticosteroids or anti-cytokine therapy (e.g. Anakinra, Tocilizumab), to a stem cell boost as a last resort in lymphoma patients who have undergone prior autologous stem cell transplantation. On the other hand, clinicians should be at high alert for infectious complications and adapt their infection surveillance and anti-infective prophylactic strategies accordingly. For example, therapeutic drug monitoring of posaconazole and meropenem levels may have revealed subtherapeutic dosing of these anti-infective agents in this patient [21]. The role of antifungal prophylaxis in the CAR T-cell patient remains inconclusive. Adequately powered studies addressing the duration of neutropenia after CAR T-cell therapy, and potential clinical determinants of invasive fungal infections, will be critical to gauge the benefit of antifungal prophylaxis in this patient collective.
Candida species are a leading cause of fungus-associated morbidity and mortality in severely immunocompromised patients [21]. On day 41, this patient developed breakthrough C. glabrata Candidemia on micafungin, in the setting of both underlying colonization and neutropenic colitis. A recent report implicated the gastrointestinal tract as major source of echinocandin drug resistance in a murine model of C. glabrata colonization and systemic dissemination [22]. Of note, breakthrough Candida infections on micafungin may occur at the employed dose level (50 mg/day IV), suggesting that this dose may have been inadequate to prevent subsequent Candidemia [23]. Though cases of C. glabrata colitis are extremely rare [24], an opportunistic infection could not be ruled out given that C. glabrata infiltrates were discovered in enteral and colonic mucosal tissue on post-mortem examination. Importantly, the patients’ clinical status deteriorated only after the stem cell boost resulted in signs of hematopoietic recovery. The paradoxical worsening of the pulmonary A. fumigatus infection is consistent with immune reconstitution inflammatory syndrome (IRIS), which has been previously described for HIV/AIDS [25] and for severely neutropenic patients with IPA [26]. In conclusion, this case emphasizes that infectious complications secondary to prolonged cytopenia influence non-relapse mortality after CAR T-cell therapy.
Abbreviations
ALCAbsolute Lymphocyte Count
ANCAbsolute Neutrophil Count
BMBone Marrow
CARChimeric antigen receptor
CBCComplete Blood Count
CRSCytokine release syndrome
CTCAECommon Terminology Criteria for Adverse Events
DLBCLDiffuse large B-cell lymphoma
FFPFresh frozen plasma
FLAIRFluid-attenuated inversion recovery
Flu/CyFludarabine/Cyclophosphamide
G-CSFGranulocyte colony stimulating factor
GIGastrointestinal
GMGalactomannan
HSPCsHematopoietic stem and progenitor cells
ICANSImmune effector cell-associated neurotoxicity syndrome
ICE-scoreImmune Effector Cell-associated Encephalopathy score
ICUIntensive care unit
IPAInvasive pulmonary aspergillosis
LDHLactate Dehydrogenase
LYRICLymphoma response to immunomodulatory therapy criteria
MDRDModification of Diet in Renal Disease
MPOMyeloperoxidase
PASPeriodic acid-Schiff
PBSCPeripheral Blood Stem Cell
VREVancomycin-resistant Enterococcus
WBCWhite Blood Count
Publisher’s Note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
Acknowledgements
Not applicable.
Authors’ contributions
The original manuscript was written by KR. KR and WGK prepared the figures. MR performed the histological examination of the bone marrow. MS reviewed and edited the manuscript. The other authors (VB1, VB2, CS, PK, FS, KD, LvB, JS, OW, MD, MvBB) contributed to patient management and participated in drafting and editing the manuscript. All authors read and approved the final manuscript.
Funding
Not applicable. Open Access funding enabled and organized by Projekt DEAL.
Availability of data and materials
The authors did not use any database, software, or tools for the writing of this manuscript.
Ethics approval and consent to participate
The authors obtained consent from the deceased patient’s next-of-kin to participate.
Consent for publication
Written informed consent was obtained from the patient’s next-of-kin for publication of this Case report and any accompanying images. A copy of the written consent is available for review by the Editor of this journal.
Competing interests
The authors declare that they have no competing interests related with this case report. | Recovered | ReactionOutcome | CC BY | 33509115 | 18,947,434 | 2021-01-28 |
What was the outcome of reaction 'Haemodynamic instability'? | Severe Candida glabrata pancolitis and fatal Aspergillus fumigatus pulmonary infection in the setting of bone marrow aplasia after CD19-directed CAR T-cell therapy - a case report.
BACKGROUND
Prolonged myelosuppression following CD19-directed CAR T-cell transfusion represents an important, yet underreported, adverse event. The resulting neutropenia and multifactorial immunosuppression can facilitate severe infectious complications.
METHODS
We describe the clinical course of a 59-year-old patient with relapsed/refractory DLBCL who received Axicabtagene-Ciloleucel (Axi-cel). The patient developed ASTCT grade I CRS and grade IV ICANS, necessitating admission to the neurological ICU and prolonged application of high-dose corticosteroids and other immunosuppressive agents. Importantly, neutropenia was profound (ANC < 100/μl), G-CSF-refractory, and prolonged, lasting more than 50 days. The patient developed severe septic shock 3 weeks after CAR transfusion while receiving anti-fungal prophylaxis with micafungin. His clinical status stabilized with broad anti-infective treatment and intensive supportive measures. An autologous stem cell backup was employed on day 46 to support hematopoietic recovery. Although the counts of the patient eventually started to recover, he developed an invasive pulmonary aspergillosis, which ultimately lead to respiratory failure and death. Postmortem examination revealed signs of Candida glabrata pancolitis.
CONCLUSIONS
This case highlights the increased risk for fatal infectious complications in patients who present with profound and prolonged cytopenia after CAR T-cell therapy. We describe a rare case of C. glabrata pancolitis associated with multifactorial immunosuppression. Although our patient succumbed to a fatal fungal infection, autologous stem cell boost was able to spur hematopoiesis and may represent an important therapeutic strategy for DLBCL patients with CAR T-cell associated bone marrow aplasia who have underwent prior stem cell harvest.
Background
When CD19-directed Chimeric Antigen Receptor (CAR) T-cell therapies were first introduced into the clinical setting, a set of distinctive side effects were observed, including Cytokine Release Syndrome (CRS) and immune effector cell-associated neurotoxicity syndrome (ICANS). As these treatments transition from large clinical trials to real-world implementation, new nuances of the side effect spectrum have emerged. This includes the observation that patients can present not only with grade 3–4 cytopenia (CTCAE v5.0), but also a syndrome of persistent cytopenia after CAR T-cell transfusion [1, 2]. Hematologic toxicity is common with one study demonstrating that neutropenia, thrombocytopenia and anemia occur in 94, 80 and 51% of patients respectively [3]. Risk factors for hematotoxicity include CRS grade, baseline cytopenia, and prior allogeneic stem cell transplantation within the last year [2, 3]. The fact that baseline hematopoietic reserve contributes to cytopenia in CAR T-cell patients may explain the variability in the incidence of hematoxicity in the real-world setting compared to the large registration trials, which set stringent hematologic exclusion criteria [4, 5]. The clinical utility of therapeutic rescue strategies that mitigate the risk of infectious complications secondary to long-term bone marrow (BM) aplasia, such as early autologous stem cell boost or Eltrombopag, remains unknown. Moreover, the relative paucity of reports concerning severe and life-threatening infections in the reported CD19-directed CAR T-cell trials necessitates the presentation of distinctive clinical courses that underline the risks of persistent cytopenia after CAR T-cell therapy in a real-world setting.
Case presentation
The 59-year-old male patient was initially diagnosed with stage IIIA follicular lymphoma in January 2018, which transformed to germinal center B-cell like DLBCL in October of the same year. Refractory to multiple cycles of Rituximab-based immunochemotherapy (Fig. 1a), the patient underwent leukapheresis for CAR T-cell therapy in April 2019. The patient experienced significant lymphoma progression during the manufacturing process of Axicabtagene ciloleucel (Axi-cel), manifesting itself in the form of malignant pleural effusions and progressive lymphadenopathy (Fig. 2a,c,e). In the six-week period between leukapheresis and lymphodepletion, the patient remained severely neutropenic after R-CHOP and developed possible invasive fungal disease (IFD) [6] (Fig. 3e) as well as E. coli septicemia secondary to a urinary tract infection. These infections were treated successfully with liposomal amphotericin B and piperacillin/tazobactam. Prior to lymphodepletion (D-5), the patient presented with an ECOG performance status of 1, intact renal and liver function, while observing residually depressed blood counts (WBC 1270/μl, ANC 700/μl, ALC 390/μl, Hemoglobin 7.2 g/dl, Platelets 20 G/l). BM histopathology showed a hypocellular marrow with no evidence of lymphoma infiltration. Analysis of lymphocyte subpopulations demonstrated severe B-cell aplasia and decreased absolute CD4+ (84/μl) and CD8+ (271/μl) counts. His anti-infective prophylaxis consisted of a combination of acyclovir, sulfamethoxazole/trimethoprim (TMP/SMZ), and posaconazole. The fludarabine/cyclophosphamide lympho-preparative regimen was applied on days − 5 to − 3 according to the provider’s protocol, followed by CAR T-cell transfusion on day 0.
Fig. 1 Overview of CAR T-cell mediated hematotoxicity and infectious complications. a Treatment course prior to CAR T-cell therapy. b Timeline of infectious complications during CAR T-cell treatment course. Positive microbiologic culture results are underlined. Bottom: Overview of utilized anti-infectives with the respective bars displaying the length of treatment. P/T = piperacillin/tazobactam, Ami = amikacin, Mero = meropenem, Vanco = vancomycin, Line = linezolid, Posa = posaconazole (p.o.), Mica = micafungin (i.v.), Amb = liposomal amphotericin B. The patient also received prophylactic acyclovir and sulfamethoxazole/trimethoprim (TMP/SMZ) during treatment. c Complete Blood Count (CBC) timeline. ANC (blue), platelet count (green), Hemoglobin (red). Transfusion events (green: platelet transfusion, red: pRBC transfusion) and G-CSF support (blue bar) are integrated in the curve. d Dynamics of Serum Inflammatory Markers. Infectious complications are superimposed above the graph. e Histopathologic analysis of BM biopsies demonstrating severe BM aplasia 1 month after CAR T-cell transfusion (Day 32, upper panel) and evidence of recovering hematopoiesis following autologous stem cell transfer (Autopsy, lower panel). Immunohistochemical staining for myeloperoxidase (= MPO) highlighting strong activation of myelopoiesis (right panel)
Fig. 2 Radiographic evidence of partial response to Axi-cel after 36 days. Contrast-enhanced CT abdomen (axial view) displaying pleural manifestations before (a) and after (b) CAR T-cell treatment. Involved paraaortic lymph nodes (red arrows) demonstrate an interval decrease in size (c-d, e-f). The inset of panel F depicts splenic hypodensities consistent with necrosis of tumor tissue secondary to immune therapy and a reduction of splenomegaly. G Graphical depiction of response over time. Tumor extent was quantified as the sum of the product of perpendicular diameters according to Lugano criteria over 3 time points and is graphed on the y-axis. H Timeline of LDH levels (U/l). The increase in LDH levels at day 25 correlated with the gastrointestinal toxicity and liver dysfunction
Fig. 3 Multi-organ toxicity secondary to CD19-directed CAR T-cell therapy. a Contrast-enhanced CT abdomen demonstrating a non-inflamed baseline state of GI mucosal tissue prior to CAR T therapy. b Panmural swelling of the sigma (left panel), ascending colon (middle panel), and stomach. c Non-pathologic CT of the brain. d Axial FLAIR-weighted (left), T1-weighted contrast-enhanced (middle), and diffusion-weighted (right) MRI displaying no evidence of cerebral edema, white matter lesions, diffusion restriction, microbleeds, meningeal enhancement or contrast enhancing lesions. e High-resolution CT thorax with bilateral fungal infiltrates observing the typical halo configuration 6 weeks prior to CAR T-cell transfusion. f On day − 3 the right-sided infiltrates have decreased in size. The left lung is collapsed due to malignant pleural effusion. g Lung parenchyma exhibiting an infiltration of non-dimorphic blastoconidial morphology consistent with Candida glabrata. h PAS staining of a lung specimen highlights septated hiphae and acute-angle branching, features consistent of with aspergillus infection
During lymphodepletion the patient developed an upper respiratory infection, presenting with a non-productive cough and a sputum culture positive for Bordetella bronchiseptica, which resolved clinically after antibiotic treatment with piperacillin/tazobactam. On day 7, the patient developed fever with a stable cardiopulmonary function and concomitant IL-6 rise (Fig. 1d), which was classified as CRS grade I according to ASTCT consensus grading [7] in the absence of positive blood cultures and other foci. Due to persistent fever refractory to antipyretic treatment, four total doses of tocilizumab (8 mg/kg) were applied over 36 h. Starting on day 9, the patient deteriorated neurologically with a depressed state of consciousness prompting the diagnosis of grade IV ICANS. The patient was transferred to the neurological ICU, and high-dose corticosteroids (methylprednisolone 1000 mg daily) were initiated. CSF-analysis displayed subtle pleocytosis, but revealed no signs of CNS infection (viral, bacterial and fungal) or meningeal involvement of the DLBCL. CT and MR imaging of the brain exhibited none of the pathological findings reported for ICANS [8] or CNS infection [9](Fig. 3c-d). After 5 days of high-dose methylprednisolone, the patient’s neurological status slowly improved, and corticosteroids could be tapered.
Partial response to Axicabtagene-Ciloleucel after 36 days according to Lugano criteria
While the patient’s initial clinical course was fraught with complications, CT staging performed at day 36 demonstrated a partial response to CAR T-cell therapy according to Lugano and Lyric criteria (Fig. 2a-g). This was particularly evident for the pleural manifestations of the underlying DLBCL, which was accompanied by an interval decrease in pleural effusions and subjective dyspnea (Fig. 2a-b). Multiple nodal sites including paraaortic (Fig. 2c-d) and parailiac lymph nodes (Fig. 2e-f) exhibited significant regression of tumor size (Fig. 2g). Moreover, the patient displayed splenic hypodensities consistent with either tumor tissue necrosis or infection-associated inflammatory changes (inset, Fig. 2f). These CT-morphologic findings were accompanied by a decrease of LDH levels (Fig. 2h).
Prolonged cytopenia lead to the development of severe neutropenic colitis and fatal fungal pneumonia
The patient presented with significant myelotoxicity and sustained transfusion dependency after CAR T-cell administration (Fig. 1c). The overall duration of profound neutropenia – defined as an ANC < 100/μl [10] – was 52 days. Because of the severity of ICANS, the clinicians chose to hold G-CSF during this time period due to concerns for risk of worsening toxicity [11].
While receiving broad anti-infectives (acyclovir, TMP/SMZ, posaconazole, meropenem), the patient developed breakthrough septic shock on day 24. He exhibited fever (39.5 °C), hypotension (70/30 mmHg), tachycardia (160/min), as well as lactic acidosis (lactate: 10.7 mmol/l). The patient was non-conversant, non-oriented, and was not able to localize symptoms. However, he had described epigastric tenderness and subtle changes in stool consistency and frequency on the previous day. As a result, abdominal CT imaging was obtained, which displayed severe pancolitis, as evidenced by pronounced mucosal thickening with edematous changes ranging from the ascending colon to the rectum (Fig. 3a-b). Labs were notable for an acute spike of serum inflammatory parameters (Il-6 > 500.000 pg/ml, CRP 5.7 mg/dl, Procalcitonin 11.2 ng/ml, Fig. 1d). Following ICU transfer, high-dose vasopressor support with norepinephrine was initiated together with volume resuscitation to maintain organ perfusion. Due to progressive loss of consciousness the patient was intubated and mechanically ventilated. To control the proinflammatory state, extracorporeal cytokine absorption (Cytosorb®) was performed, which resulted in a decrease of soluble inflammatory markers in the subsequent days. Arterial blood cultures were positive for vancomycin-resistant enterococci (VRE), and the antibiotic treatment was escalated to include linezolid along with meropenem (Fig. 1b). The ICU team transitioned antifungal prophylaxis from posaconazole to an echinocandine (micafungin 50 mg IV) due to ECG changes and concerns for drug interactions on day 24. Though he remained in critical condition, in the coming weeks his clinical condition stabilized and both the catecholamine rate and volume support could be reduced. To determine the origin of sustained myelosuppression, a bone marrow biopsy was obtained, which depicted a hypocellular marrow and severe aplasia affecting all hematopoietic lineages (Fig. 1e). On days 41 and 49, surveillance blood cultures were positive for Candida glabrata, a commensal fungal organism of human mucosal tissues [12] harboring an intrinsic azole resistance [13]. Susceptibility testing confirmed the azole-resistance of C. glabrata isolates. The antimycotic therapy was escalated from micafungin to liposomal amphotericin B. C. glabrata likely disseminated to the bloodstream secondary to the described gastrointestinal toxicity and was previously discovered on rectal swab (Fig. 1b) and fecal culture (day − 51).
Due to sustained neutropenia, BM aplasia and the availability of a suitable apheresis product, the CAR T-cell Taskforce proceeded with a stem cell boost of previously collected autologous CD34+ cells (3,1 × 106 cells) on day 46. The combination of a sudden rise in serum inflammatory markers and a strongly positive serum galactomannan (GM) assay on day 49 prompted diagnostic bronchoscopy, which revealed a diffuse infiltrate of alveolar and peri-bronchial tissue by Aspergillus fumigatus, consistent with fulminant invasive fungal pneumonia. Over the next week, the patient became increasingly hemodynamically unstable with poor peripheral oxygenation. Repeat bronchoscopy with bronchial lavage was positive for A. fumigatus and C. glabrata. After 50 days of G-CSF refractory aplasia, the autologous stem cells slowly engrafted leading to neutrophil recovery. However, this likely exacerbated the local inflammatory reaction in the lung, contributing to rapid deterioration of his respiratory status. Despite extensive supportive measures, the patient died on day 58 after CAR T-cell transfusion. Cause of death was confirmed by autopsy as invasive fungal pneumonia with multi-organ septic spread. Post-mortem examination revealed Candida spores in intestinal, colonic and rectal tissue. Of note, histopathologic BM analysis revealed signs of burgeoning hematopoietic regeneration (Fig. 1e).
Discussion and conclusions
Recent studies have shed light on the high incidence of prolonged and profound neutropenia after adoptive immunotherapy with CD19-specific CAR T-cells [1–3]. Clinical sequalae include severe infectious complications, which have emerged as the number one cause of long-term non-relapse mortality after CAR T-cell therapy [14]. In a seminal study, Hill and colleagues demonstrate that infectious complications are common with a cumulative incidence of 23% in the first 28 days after CAR T-cell transfusion and 14% between days 29–90. While bacterial infections were most common in the first month, viral infections – especially respiratory viruses – predominated after day 29, likely as a result of an impaired adaptive immune response due to B-cell aplasia [15]. Overall, most infections were mild to moderate and fatal infections were rare. Invasive mold infections were uncommon, ranging from 1 to 7% in CAR T-cell recipients [15–17]. In multivariate analyses, the use of systemic corticosteroids for the management of CRS or ICANS has emerged as a major risk factor of infection [18]. Certain inflammatory signatures – such as the “double peaks of IL-6” pattern observed in our patient – have been shown to confer an especially high risk of life-threatening infection [19].
This case highlights the combination of factors that precipitate a high risk of infectious complications in a CAR T-cell patient. First, the heavily pre-treated patient displayed B-cell aplasia and a diminished hematopoietic reserve (e.g. trilineage cytopenia) prior to lymphodepletion. Second, the patient developed classic complications of CAR T-cell therapy such as CRS and severe and prolonged ICANS, reflecting a pro-inflammatory state that represents an important risk factor for developing infections in CAR T-cell patients [16]. The subsequent application of high-dose corticosteroids impaired both innate and adaptive immunity [20]. Third, pancytopenia was profound, prolonged and not able to be reverted by growth factor support. Fourth, the patient had a history of infectious complications, including a course of fungal pneumonia 6 weeks prior to lymphodepletion, likely flaring up in the setting of the above three factors.
Our patient developed severe septic shock secondary to neutropenic colitis on day 24, highlighting the risk of a watch-and-wait approach to prolonged neutropenia after CAR T-cell therapy. A two-pronged approach to management appears prescient. On the one hand, measures to propagate hematopoietic recovery should be exhausted (causal therapy). This can range from G-CSF stimulation, to a trial of pulse-dose corticosteroids or anti-cytokine therapy (e.g. Anakinra, Tocilizumab), to a stem cell boost as a last resort in lymphoma patients who have undergone prior autologous stem cell transplantation. On the other hand, clinicians should be at high alert for infectious complications and adapt their infection surveillance and anti-infective prophylactic strategies accordingly. For example, therapeutic drug monitoring of posaconazole and meropenem levels may have revealed subtherapeutic dosing of these anti-infective agents in this patient [21]. The role of antifungal prophylaxis in the CAR T-cell patient remains inconclusive. Adequately powered studies addressing the duration of neutropenia after CAR T-cell therapy, and potential clinical determinants of invasive fungal infections, will be critical to gauge the benefit of antifungal prophylaxis in this patient collective.
Candida species are a leading cause of fungus-associated morbidity and mortality in severely immunocompromised patients [21]. On day 41, this patient developed breakthrough C. glabrata Candidemia on micafungin, in the setting of both underlying colonization and neutropenic colitis. A recent report implicated the gastrointestinal tract as major source of echinocandin drug resistance in a murine model of C. glabrata colonization and systemic dissemination [22]. Of note, breakthrough Candida infections on micafungin may occur at the employed dose level (50 mg/day IV), suggesting that this dose may have been inadequate to prevent subsequent Candidemia [23]. Though cases of C. glabrata colitis are extremely rare [24], an opportunistic infection could not be ruled out given that C. glabrata infiltrates were discovered in enteral and colonic mucosal tissue on post-mortem examination. Importantly, the patients’ clinical status deteriorated only after the stem cell boost resulted in signs of hematopoietic recovery. The paradoxical worsening of the pulmonary A. fumigatus infection is consistent with immune reconstitution inflammatory syndrome (IRIS), which has been previously described for HIV/AIDS [25] and for severely neutropenic patients with IPA [26]. In conclusion, this case emphasizes that infectious complications secondary to prolonged cytopenia influence non-relapse mortality after CAR T-cell therapy.
Abbreviations
ALCAbsolute Lymphocyte Count
ANCAbsolute Neutrophil Count
BMBone Marrow
CARChimeric antigen receptor
CBCComplete Blood Count
CRSCytokine release syndrome
CTCAECommon Terminology Criteria for Adverse Events
DLBCLDiffuse large B-cell lymphoma
FFPFresh frozen plasma
FLAIRFluid-attenuated inversion recovery
Flu/CyFludarabine/Cyclophosphamide
G-CSFGranulocyte colony stimulating factor
GIGastrointestinal
GMGalactomannan
HSPCsHematopoietic stem and progenitor cells
ICANSImmune effector cell-associated neurotoxicity syndrome
ICE-scoreImmune Effector Cell-associated Encephalopathy score
ICUIntensive care unit
IPAInvasive pulmonary aspergillosis
LDHLactate Dehydrogenase
LYRICLymphoma response to immunomodulatory therapy criteria
MDRDModification of Diet in Renal Disease
MPOMyeloperoxidase
PASPeriodic acid-Schiff
PBSCPeripheral Blood Stem Cell
VREVancomycin-resistant Enterococcus
WBCWhite Blood Count
Publisher’s Note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
Acknowledgements
Not applicable.
Authors’ contributions
The original manuscript was written by KR. KR and WGK prepared the figures. MR performed the histological examination of the bone marrow. MS reviewed and edited the manuscript. The other authors (VB1, VB2, CS, PK, FS, KD, LvB, JS, OW, MD, MvBB) contributed to patient management and participated in drafting and editing the manuscript. All authors read and approved the final manuscript.
Funding
Not applicable. Open Access funding enabled and organized by Projekt DEAL.
Availability of data and materials
The authors did not use any database, software, or tools for the writing of this manuscript.
Ethics approval and consent to participate
The authors obtained consent from the deceased patient’s next-of-kin to participate.
Consent for publication
Written informed consent was obtained from the patient’s next-of-kin for publication of this Case report and any accompanying images. A copy of the written consent is available for review by the Editor of this journal.
Competing interests
The authors declare that they have no competing interests related with this case report. | Fatal | ReactionOutcome | CC BY | 33509115 | 18,947,434 | 2021-01-28 |
What was the outcome of reaction 'Myelosuppression'? | Severe Candida glabrata pancolitis and fatal Aspergillus fumigatus pulmonary infection in the setting of bone marrow aplasia after CD19-directed CAR T-cell therapy - a case report.
BACKGROUND
Prolonged myelosuppression following CD19-directed CAR T-cell transfusion represents an important, yet underreported, adverse event. The resulting neutropenia and multifactorial immunosuppression can facilitate severe infectious complications.
METHODS
We describe the clinical course of a 59-year-old patient with relapsed/refractory DLBCL who received Axicabtagene-Ciloleucel (Axi-cel). The patient developed ASTCT grade I CRS and grade IV ICANS, necessitating admission to the neurological ICU and prolonged application of high-dose corticosteroids and other immunosuppressive agents. Importantly, neutropenia was profound (ANC < 100/μl), G-CSF-refractory, and prolonged, lasting more than 50 days. The patient developed severe septic shock 3 weeks after CAR transfusion while receiving anti-fungal prophylaxis with micafungin. His clinical status stabilized with broad anti-infective treatment and intensive supportive measures. An autologous stem cell backup was employed on day 46 to support hematopoietic recovery. Although the counts of the patient eventually started to recover, he developed an invasive pulmonary aspergillosis, which ultimately lead to respiratory failure and death. Postmortem examination revealed signs of Candida glabrata pancolitis.
CONCLUSIONS
This case highlights the increased risk for fatal infectious complications in patients who present with profound and prolonged cytopenia after CAR T-cell therapy. We describe a rare case of C. glabrata pancolitis associated with multifactorial immunosuppression. Although our patient succumbed to a fatal fungal infection, autologous stem cell boost was able to spur hematopoiesis and may represent an important therapeutic strategy for DLBCL patients with CAR T-cell associated bone marrow aplasia who have underwent prior stem cell harvest.
Background
When CD19-directed Chimeric Antigen Receptor (CAR) T-cell therapies were first introduced into the clinical setting, a set of distinctive side effects were observed, including Cytokine Release Syndrome (CRS) and immune effector cell-associated neurotoxicity syndrome (ICANS). As these treatments transition from large clinical trials to real-world implementation, new nuances of the side effect spectrum have emerged. This includes the observation that patients can present not only with grade 3–4 cytopenia (CTCAE v5.0), but also a syndrome of persistent cytopenia after CAR T-cell transfusion [1, 2]. Hematologic toxicity is common with one study demonstrating that neutropenia, thrombocytopenia and anemia occur in 94, 80 and 51% of patients respectively [3]. Risk factors for hematotoxicity include CRS grade, baseline cytopenia, and prior allogeneic stem cell transplantation within the last year [2, 3]. The fact that baseline hematopoietic reserve contributes to cytopenia in CAR T-cell patients may explain the variability in the incidence of hematoxicity in the real-world setting compared to the large registration trials, which set stringent hematologic exclusion criteria [4, 5]. The clinical utility of therapeutic rescue strategies that mitigate the risk of infectious complications secondary to long-term bone marrow (BM) aplasia, such as early autologous stem cell boost or Eltrombopag, remains unknown. Moreover, the relative paucity of reports concerning severe and life-threatening infections in the reported CD19-directed CAR T-cell trials necessitates the presentation of distinctive clinical courses that underline the risks of persistent cytopenia after CAR T-cell therapy in a real-world setting.
Case presentation
The 59-year-old male patient was initially diagnosed with stage IIIA follicular lymphoma in January 2018, which transformed to germinal center B-cell like DLBCL in October of the same year. Refractory to multiple cycles of Rituximab-based immunochemotherapy (Fig. 1a), the patient underwent leukapheresis for CAR T-cell therapy in April 2019. The patient experienced significant lymphoma progression during the manufacturing process of Axicabtagene ciloleucel (Axi-cel), manifesting itself in the form of malignant pleural effusions and progressive lymphadenopathy (Fig. 2a,c,e). In the six-week period between leukapheresis and lymphodepletion, the patient remained severely neutropenic after R-CHOP and developed possible invasive fungal disease (IFD) [6] (Fig. 3e) as well as E. coli septicemia secondary to a urinary tract infection. These infections were treated successfully with liposomal amphotericin B and piperacillin/tazobactam. Prior to lymphodepletion (D-5), the patient presented with an ECOG performance status of 1, intact renal and liver function, while observing residually depressed blood counts (WBC 1270/μl, ANC 700/μl, ALC 390/μl, Hemoglobin 7.2 g/dl, Platelets 20 G/l). BM histopathology showed a hypocellular marrow with no evidence of lymphoma infiltration. Analysis of lymphocyte subpopulations demonstrated severe B-cell aplasia and decreased absolute CD4+ (84/μl) and CD8+ (271/μl) counts. His anti-infective prophylaxis consisted of a combination of acyclovir, sulfamethoxazole/trimethoprim (TMP/SMZ), and posaconazole. The fludarabine/cyclophosphamide lympho-preparative regimen was applied on days − 5 to − 3 according to the provider’s protocol, followed by CAR T-cell transfusion on day 0.
Fig. 1 Overview of CAR T-cell mediated hematotoxicity and infectious complications. a Treatment course prior to CAR T-cell therapy. b Timeline of infectious complications during CAR T-cell treatment course. Positive microbiologic culture results are underlined. Bottom: Overview of utilized anti-infectives with the respective bars displaying the length of treatment. P/T = piperacillin/tazobactam, Ami = amikacin, Mero = meropenem, Vanco = vancomycin, Line = linezolid, Posa = posaconazole (p.o.), Mica = micafungin (i.v.), Amb = liposomal amphotericin B. The patient also received prophylactic acyclovir and sulfamethoxazole/trimethoprim (TMP/SMZ) during treatment. c Complete Blood Count (CBC) timeline. ANC (blue), platelet count (green), Hemoglobin (red). Transfusion events (green: platelet transfusion, red: pRBC transfusion) and G-CSF support (blue bar) are integrated in the curve. d Dynamics of Serum Inflammatory Markers. Infectious complications are superimposed above the graph. e Histopathologic analysis of BM biopsies demonstrating severe BM aplasia 1 month after CAR T-cell transfusion (Day 32, upper panel) and evidence of recovering hematopoiesis following autologous stem cell transfer (Autopsy, lower panel). Immunohistochemical staining for myeloperoxidase (= MPO) highlighting strong activation of myelopoiesis (right panel)
Fig. 2 Radiographic evidence of partial response to Axi-cel after 36 days. Contrast-enhanced CT abdomen (axial view) displaying pleural manifestations before (a) and after (b) CAR T-cell treatment. Involved paraaortic lymph nodes (red arrows) demonstrate an interval decrease in size (c-d, e-f). The inset of panel F depicts splenic hypodensities consistent with necrosis of tumor tissue secondary to immune therapy and a reduction of splenomegaly. G Graphical depiction of response over time. Tumor extent was quantified as the sum of the product of perpendicular diameters according to Lugano criteria over 3 time points and is graphed on the y-axis. H Timeline of LDH levels (U/l). The increase in LDH levels at day 25 correlated with the gastrointestinal toxicity and liver dysfunction
Fig. 3 Multi-organ toxicity secondary to CD19-directed CAR T-cell therapy. a Contrast-enhanced CT abdomen demonstrating a non-inflamed baseline state of GI mucosal tissue prior to CAR T therapy. b Panmural swelling of the sigma (left panel), ascending colon (middle panel), and stomach. c Non-pathologic CT of the brain. d Axial FLAIR-weighted (left), T1-weighted contrast-enhanced (middle), and diffusion-weighted (right) MRI displaying no evidence of cerebral edema, white matter lesions, diffusion restriction, microbleeds, meningeal enhancement or contrast enhancing lesions. e High-resolution CT thorax with bilateral fungal infiltrates observing the typical halo configuration 6 weeks prior to CAR T-cell transfusion. f On day − 3 the right-sided infiltrates have decreased in size. The left lung is collapsed due to malignant pleural effusion. g Lung parenchyma exhibiting an infiltration of non-dimorphic blastoconidial morphology consistent with Candida glabrata. h PAS staining of a lung specimen highlights septated hiphae and acute-angle branching, features consistent of with aspergillus infection
During lymphodepletion the patient developed an upper respiratory infection, presenting with a non-productive cough and a sputum culture positive for Bordetella bronchiseptica, which resolved clinically after antibiotic treatment with piperacillin/tazobactam. On day 7, the patient developed fever with a stable cardiopulmonary function and concomitant IL-6 rise (Fig. 1d), which was classified as CRS grade I according to ASTCT consensus grading [7] in the absence of positive blood cultures and other foci. Due to persistent fever refractory to antipyretic treatment, four total doses of tocilizumab (8 mg/kg) were applied over 36 h. Starting on day 9, the patient deteriorated neurologically with a depressed state of consciousness prompting the diagnosis of grade IV ICANS. The patient was transferred to the neurological ICU, and high-dose corticosteroids (methylprednisolone 1000 mg daily) were initiated. CSF-analysis displayed subtle pleocytosis, but revealed no signs of CNS infection (viral, bacterial and fungal) or meningeal involvement of the DLBCL. CT and MR imaging of the brain exhibited none of the pathological findings reported for ICANS [8] or CNS infection [9](Fig. 3c-d). After 5 days of high-dose methylprednisolone, the patient’s neurological status slowly improved, and corticosteroids could be tapered.
Partial response to Axicabtagene-Ciloleucel after 36 days according to Lugano criteria
While the patient’s initial clinical course was fraught with complications, CT staging performed at day 36 demonstrated a partial response to CAR T-cell therapy according to Lugano and Lyric criteria (Fig. 2a-g). This was particularly evident for the pleural manifestations of the underlying DLBCL, which was accompanied by an interval decrease in pleural effusions and subjective dyspnea (Fig. 2a-b). Multiple nodal sites including paraaortic (Fig. 2c-d) and parailiac lymph nodes (Fig. 2e-f) exhibited significant regression of tumor size (Fig. 2g). Moreover, the patient displayed splenic hypodensities consistent with either tumor tissue necrosis or infection-associated inflammatory changes (inset, Fig. 2f). These CT-morphologic findings were accompanied by a decrease of LDH levels (Fig. 2h).
Prolonged cytopenia lead to the development of severe neutropenic colitis and fatal fungal pneumonia
The patient presented with significant myelotoxicity and sustained transfusion dependency after CAR T-cell administration (Fig. 1c). The overall duration of profound neutropenia – defined as an ANC < 100/μl [10] – was 52 days. Because of the severity of ICANS, the clinicians chose to hold G-CSF during this time period due to concerns for risk of worsening toxicity [11].
While receiving broad anti-infectives (acyclovir, TMP/SMZ, posaconazole, meropenem), the patient developed breakthrough septic shock on day 24. He exhibited fever (39.5 °C), hypotension (70/30 mmHg), tachycardia (160/min), as well as lactic acidosis (lactate: 10.7 mmol/l). The patient was non-conversant, non-oriented, and was not able to localize symptoms. However, he had described epigastric tenderness and subtle changes in stool consistency and frequency on the previous day. As a result, abdominal CT imaging was obtained, which displayed severe pancolitis, as evidenced by pronounced mucosal thickening with edematous changes ranging from the ascending colon to the rectum (Fig. 3a-b). Labs were notable for an acute spike of serum inflammatory parameters (Il-6 > 500.000 pg/ml, CRP 5.7 mg/dl, Procalcitonin 11.2 ng/ml, Fig. 1d). Following ICU transfer, high-dose vasopressor support with norepinephrine was initiated together with volume resuscitation to maintain organ perfusion. Due to progressive loss of consciousness the patient was intubated and mechanically ventilated. To control the proinflammatory state, extracorporeal cytokine absorption (Cytosorb®) was performed, which resulted in a decrease of soluble inflammatory markers in the subsequent days. Arterial blood cultures were positive for vancomycin-resistant enterococci (VRE), and the antibiotic treatment was escalated to include linezolid along with meropenem (Fig. 1b). The ICU team transitioned antifungal prophylaxis from posaconazole to an echinocandine (micafungin 50 mg IV) due to ECG changes and concerns for drug interactions on day 24. Though he remained in critical condition, in the coming weeks his clinical condition stabilized and both the catecholamine rate and volume support could be reduced. To determine the origin of sustained myelosuppression, a bone marrow biopsy was obtained, which depicted a hypocellular marrow and severe aplasia affecting all hematopoietic lineages (Fig. 1e). On days 41 and 49, surveillance blood cultures were positive for Candida glabrata, a commensal fungal organism of human mucosal tissues [12] harboring an intrinsic azole resistance [13]. Susceptibility testing confirmed the azole-resistance of C. glabrata isolates. The antimycotic therapy was escalated from micafungin to liposomal amphotericin B. C. glabrata likely disseminated to the bloodstream secondary to the described gastrointestinal toxicity and was previously discovered on rectal swab (Fig. 1b) and fecal culture (day − 51).
Due to sustained neutropenia, BM aplasia and the availability of a suitable apheresis product, the CAR T-cell Taskforce proceeded with a stem cell boost of previously collected autologous CD34+ cells (3,1 × 106 cells) on day 46. The combination of a sudden rise in serum inflammatory markers and a strongly positive serum galactomannan (GM) assay on day 49 prompted diagnostic bronchoscopy, which revealed a diffuse infiltrate of alveolar and peri-bronchial tissue by Aspergillus fumigatus, consistent with fulminant invasive fungal pneumonia. Over the next week, the patient became increasingly hemodynamically unstable with poor peripheral oxygenation. Repeat bronchoscopy with bronchial lavage was positive for A. fumigatus and C. glabrata. After 50 days of G-CSF refractory aplasia, the autologous stem cells slowly engrafted leading to neutrophil recovery. However, this likely exacerbated the local inflammatory reaction in the lung, contributing to rapid deterioration of his respiratory status. Despite extensive supportive measures, the patient died on day 58 after CAR T-cell transfusion. Cause of death was confirmed by autopsy as invasive fungal pneumonia with multi-organ septic spread. Post-mortem examination revealed Candida spores in intestinal, colonic and rectal tissue. Of note, histopathologic BM analysis revealed signs of burgeoning hematopoietic regeneration (Fig. 1e).
Discussion and conclusions
Recent studies have shed light on the high incidence of prolonged and profound neutropenia after adoptive immunotherapy with CD19-specific CAR T-cells [1–3]. Clinical sequalae include severe infectious complications, which have emerged as the number one cause of long-term non-relapse mortality after CAR T-cell therapy [14]. In a seminal study, Hill and colleagues demonstrate that infectious complications are common with a cumulative incidence of 23% in the first 28 days after CAR T-cell transfusion and 14% between days 29–90. While bacterial infections were most common in the first month, viral infections – especially respiratory viruses – predominated after day 29, likely as a result of an impaired adaptive immune response due to B-cell aplasia [15]. Overall, most infections were mild to moderate and fatal infections were rare. Invasive mold infections were uncommon, ranging from 1 to 7% in CAR T-cell recipients [15–17]. In multivariate analyses, the use of systemic corticosteroids for the management of CRS or ICANS has emerged as a major risk factor of infection [18]. Certain inflammatory signatures – such as the “double peaks of IL-6” pattern observed in our patient – have been shown to confer an especially high risk of life-threatening infection [19].
This case highlights the combination of factors that precipitate a high risk of infectious complications in a CAR T-cell patient. First, the heavily pre-treated patient displayed B-cell aplasia and a diminished hematopoietic reserve (e.g. trilineage cytopenia) prior to lymphodepletion. Second, the patient developed classic complications of CAR T-cell therapy such as CRS and severe and prolonged ICANS, reflecting a pro-inflammatory state that represents an important risk factor for developing infections in CAR T-cell patients [16]. The subsequent application of high-dose corticosteroids impaired both innate and adaptive immunity [20]. Third, pancytopenia was profound, prolonged and not able to be reverted by growth factor support. Fourth, the patient had a history of infectious complications, including a course of fungal pneumonia 6 weeks prior to lymphodepletion, likely flaring up in the setting of the above three factors.
Our patient developed severe septic shock secondary to neutropenic colitis on day 24, highlighting the risk of a watch-and-wait approach to prolonged neutropenia after CAR T-cell therapy. A two-pronged approach to management appears prescient. On the one hand, measures to propagate hematopoietic recovery should be exhausted (causal therapy). This can range from G-CSF stimulation, to a trial of pulse-dose corticosteroids or anti-cytokine therapy (e.g. Anakinra, Tocilizumab), to a stem cell boost as a last resort in lymphoma patients who have undergone prior autologous stem cell transplantation. On the other hand, clinicians should be at high alert for infectious complications and adapt their infection surveillance and anti-infective prophylactic strategies accordingly. For example, therapeutic drug monitoring of posaconazole and meropenem levels may have revealed subtherapeutic dosing of these anti-infective agents in this patient [21]. The role of antifungal prophylaxis in the CAR T-cell patient remains inconclusive. Adequately powered studies addressing the duration of neutropenia after CAR T-cell therapy, and potential clinical determinants of invasive fungal infections, will be critical to gauge the benefit of antifungal prophylaxis in this patient collective.
Candida species are a leading cause of fungus-associated morbidity and mortality in severely immunocompromised patients [21]. On day 41, this patient developed breakthrough C. glabrata Candidemia on micafungin, in the setting of both underlying colonization and neutropenic colitis. A recent report implicated the gastrointestinal tract as major source of echinocandin drug resistance in a murine model of C. glabrata colonization and systemic dissemination [22]. Of note, breakthrough Candida infections on micafungin may occur at the employed dose level (50 mg/day IV), suggesting that this dose may have been inadequate to prevent subsequent Candidemia [23]. Though cases of C. glabrata colitis are extremely rare [24], an opportunistic infection could not be ruled out given that C. glabrata infiltrates were discovered in enteral and colonic mucosal tissue on post-mortem examination. Importantly, the patients’ clinical status deteriorated only after the stem cell boost resulted in signs of hematopoietic recovery. The paradoxical worsening of the pulmonary A. fumigatus infection is consistent with immune reconstitution inflammatory syndrome (IRIS), which has been previously described for HIV/AIDS [25] and for severely neutropenic patients with IPA [26]. In conclusion, this case emphasizes that infectious complications secondary to prolonged cytopenia influence non-relapse mortality after CAR T-cell therapy.
Abbreviations
ALCAbsolute Lymphocyte Count
ANCAbsolute Neutrophil Count
BMBone Marrow
CARChimeric antigen receptor
CBCComplete Blood Count
CRSCytokine release syndrome
CTCAECommon Terminology Criteria for Adverse Events
DLBCLDiffuse large B-cell lymphoma
FFPFresh frozen plasma
FLAIRFluid-attenuated inversion recovery
Flu/CyFludarabine/Cyclophosphamide
G-CSFGranulocyte colony stimulating factor
GIGastrointestinal
GMGalactomannan
HSPCsHematopoietic stem and progenitor cells
ICANSImmune effector cell-associated neurotoxicity syndrome
ICE-scoreImmune Effector Cell-associated Encephalopathy score
ICUIntensive care unit
IPAInvasive pulmonary aspergillosis
LDHLactate Dehydrogenase
LYRICLymphoma response to immunomodulatory therapy criteria
MDRDModification of Diet in Renal Disease
MPOMyeloperoxidase
PASPeriodic acid-Schiff
PBSCPeripheral Blood Stem Cell
VREVancomycin-resistant Enterococcus
WBCWhite Blood Count
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Acknowledgements
Not applicable.
Authors’ contributions
The original manuscript was written by KR. KR and WGK prepared the figures. MR performed the histological examination of the bone marrow. MS reviewed and edited the manuscript. The other authors (VB1, VB2, CS, PK, FS, KD, LvB, JS, OW, MD, MvBB) contributed to patient management and participated in drafting and editing the manuscript. All authors read and approved the final manuscript.
Funding
Not applicable. Open Access funding enabled and organized by Projekt DEAL.
Availability of data and materials
The authors did not use any database, software, or tools for the writing of this manuscript.
Ethics approval and consent to participate
The authors obtained consent from the deceased patient’s next-of-kin to participate.
Consent for publication
Written informed consent was obtained from the patient’s next-of-kin for publication of this Case report and any accompanying images. A copy of the written consent is available for review by the Editor of this journal.
Competing interests
The authors declare that they have no competing interests related with this case report. | Fatal | ReactionOutcome | CC BY | 33509115 | 18,947,434 | 2021-01-28 |
What was the outcome of reaction 'Neutropenia'? | Severe Candida glabrata pancolitis and fatal Aspergillus fumigatus pulmonary infection in the setting of bone marrow aplasia after CD19-directed CAR T-cell therapy - a case report.
BACKGROUND
Prolonged myelosuppression following CD19-directed CAR T-cell transfusion represents an important, yet underreported, adverse event. The resulting neutropenia and multifactorial immunosuppression can facilitate severe infectious complications.
METHODS
We describe the clinical course of a 59-year-old patient with relapsed/refractory DLBCL who received Axicabtagene-Ciloleucel (Axi-cel). The patient developed ASTCT grade I CRS and grade IV ICANS, necessitating admission to the neurological ICU and prolonged application of high-dose corticosteroids and other immunosuppressive agents. Importantly, neutropenia was profound (ANC < 100/μl), G-CSF-refractory, and prolonged, lasting more than 50 days. The patient developed severe septic shock 3 weeks after CAR transfusion while receiving anti-fungal prophylaxis with micafungin. His clinical status stabilized with broad anti-infective treatment and intensive supportive measures. An autologous stem cell backup was employed on day 46 to support hematopoietic recovery. Although the counts of the patient eventually started to recover, he developed an invasive pulmonary aspergillosis, which ultimately lead to respiratory failure and death. Postmortem examination revealed signs of Candida glabrata pancolitis.
CONCLUSIONS
This case highlights the increased risk for fatal infectious complications in patients who present with profound and prolonged cytopenia after CAR T-cell therapy. We describe a rare case of C. glabrata pancolitis associated with multifactorial immunosuppression. Although our patient succumbed to a fatal fungal infection, autologous stem cell boost was able to spur hematopoiesis and may represent an important therapeutic strategy for DLBCL patients with CAR T-cell associated bone marrow aplasia who have underwent prior stem cell harvest.
Background
When CD19-directed Chimeric Antigen Receptor (CAR) T-cell therapies were first introduced into the clinical setting, a set of distinctive side effects were observed, including Cytokine Release Syndrome (CRS) and immune effector cell-associated neurotoxicity syndrome (ICANS). As these treatments transition from large clinical trials to real-world implementation, new nuances of the side effect spectrum have emerged. This includes the observation that patients can present not only with grade 3–4 cytopenia (CTCAE v5.0), but also a syndrome of persistent cytopenia after CAR T-cell transfusion [1, 2]. Hematologic toxicity is common with one study demonstrating that neutropenia, thrombocytopenia and anemia occur in 94, 80 and 51% of patients respectively [3]. Risk factors for hematotoxicity include CRS grade, baseline cytopenia, and prior allogeneic stem cell transplantation within the last year [2, 3]. The fact that baseline hematopoietic reserve contributes to cytopenia in CAR T-cell patients may explain the variability in the incidence of hematoxicity in the real-world setting compared to the large registration trials, which set stringent hematologic exclusion criteria [4, 5]. The clinical utility of therapeutic rescue strategies that mitigate the risk of infectious complications secondary to long-term bone marrow (BM) aplasia, such as early autologous stem cell boost or Eltrombopag, remains unknown. Moreover, the relative paucity of reports concerning severe and life-threatening infections in the reported CD19-directed CAR T-cell trials necessitates the presentation of distinctive clinical courses that underline the risks of persistent cytopenia after CAR T-cell therapy in a real-world setting.
Case presentation
The 59-year-old male patient was initially diagnosed with stage IIIA follicular lymphoma in January 2018, which transformed to germinal center B-cell like DLBCL in October of the same year. Refractory to multiple cycles of Rituximab-based immunochemotherapy (Fig. 1a), the patient underwent leukapheresis for CAR T-cell therapy in April 2019. The patient experienced significant lymphoma progression during the manufacturing process of Axicabtagene ciloleucel (Axi-cel), manifesting itself in the form of malignant pleural effusions and progressive lymphadenopathy (Fig. 2a,c,e). In the six-week period between leukapheresis and lymphodepletion, the patient remained severely neutropenic after R-CHOP and developed possible invasive fungal disease (IFD) [6] (Fig. 3e) as well as E. coli septicemia secondary to a urinary tract infection. These infections were treated successfully with liposomal amphotericin B and piperacillin/tazobactam. Prior to lymphodepletion (D-5), the patient presented with an ECOG performance status of 1, intact renal and liver function, while observing residually depressed blood counts (WBC 1270/μl, ANC 700/μl, ALC 390/μl, Hemoglobin 7.2 g/dl, Platelets 20 G/l). BM histopathology showed a hypocellular marrow with no evidence of lymphoma infiltration. Analysis of lymphocyte subpopulations demonstrated severe B-cell aplasia and decreased absolute CD4+ (84/μl) and CD8+ (271/μl) counts. His anti-infective prophylaxis consisted of a combination of acyclovir, sulfamethoxazole/trimethoprim (TMP/SMZ), and posaconazole. The fludarabine/cyclophosphamide lympho-preparative regimen was applied on days − 5 to − 3 according to the provider’s protocol, followed by CAR T-cell transfusion on day 0.
Fig. 1 Overview of CAR T-cell mediated hematotoxicity and infectious complications. a Treatment course prior to CAR T-cell therapy. b Timeline of infectious complications during CAR T-cell treatment course. Positive microbiologic culture results are underlined. Bottom: Overview of utilized anti-infectives with the respective bars displaying the length of treatment. P/T = piperacillin/tazobactam, Ami = amikacin, Mero = meropenem, Vanco = vancomycin, Line = linezolid, Posa = posaconazole (p.o.), Mica = micafungin (i.v.), Amb = liposomal amphotericin B. The patient also received prophylactic acyclovir and sulfamethoxazole/trimethoprim (TMP/SMZ) during treatment. c Complete Blood Count (CBC) timeline. ANC (blue), platelet count (green), Hemoglobin (red). Transfusion events (green: platelet transfusion, red: pRBC transfusion) and G-CSF support (blue bar) are integrated in the curve. d Dynamics of Serum Inflammatory Markers. Infectious complications are superimposed above the graph. e Histopathologic analysis of BM biopsies demonstrating severe BM aplasia 1 month after CAR T-cell transfusion (Day 32, upper panel) and evidence of recovering hematopoiesis following autologous stem cell transfer (Autopsy, lower panel). Immunohistochemical staining for myeloperoxidase (= MPO) highlighting strong activation of myelopoiesis (right panel)
Fig. 2 Radiographic evidence of partial response to Axi-cel after 36 days. Contrast-enhanced CT abdomen (axial view) displaying pleural manifestations before (a) and after (b) CAR T-cell treatment. Involved paraaortic lymph nodes (red arrows) demonstrate an interval decrease in size (c-d, e-f). The inset of panel F depicts splenic hypodensities consistent with necrosis of tumor tissue secondary to immune therapy and a reduction of splenomegaly. G Graphical depiction of response over time. Tumor extent was quantified as the sum of the product of perpendicular diameters according to Lugano criteria over 3 time points and is graphed on the y-axis. H Timeline of LDH levels (U/l). The increase in LDH levels at day 25 correlated with the gastrointestinal toxicity and liver dysfunction
Fig. 3 Multi-organ toxicity secondary to CD19-directed CAR T-cell therapy. a Contrast-enhanced CT abdomen demonstrating a non-inflamed baseline state of GI mucosal tissue prior to CAR T therapy. b Panmural swelling of the sigma (left panel), ascending colon (middle panel), and stomach. c Non-pathologic CT of the brain. d Axial FLAIR-weighted (left), T1-weighted contrast-enhanced (middle), and diffusion-weighted (right) MRI displaying no evidence of cerebral edema, white matter lesions, diffusion restriction, microbleeds, meningeal enhancement or contrast enhancing lesions. e High-resolution CT thorax with bilateral fungal infiltrates observing the typical halo configuration 6 weeks prior to CAR T-cell transfusion. f On day − 3 the right-sided infiltrates have decreased in size. The left lung is collapsed due to malignant pleural effusion. g Lung parenchyma exhibiting an infiltration of non-dimorphic blastoconidial morphology consistent with Candida glabrata. h PAS staining of a lung specimen highlights septated hiphae and acute-angle branching, features consistent of with aspergillus infection
During lymphodepletion the patient developed an upper respiratory infection, presenting with a non-productive cough and a sputum culture positive for Bordetella bronchiseptica, which resolved clinically after antibiotic treatment with piperacillin/tazobactam. On day 7, the patient developed fever with a stable cardiopulmonary function and concomitant IL-6 rise (Fig. 1d), which was classified as CRS grade I according to ASTCT consensus grading [7] in the absence of positive blood cultures and other foci. Due to persistent fever refractory to antipyretic treatment, four total doses of tocilizumab (8 mg/kg) were applied over 36 h. Starting on day 9, the patient deteriorated neurologically with a depressed state of consciousness prompting the diagnosis of grade IV ICANS. The patient was transferred to the neurological ICU, and high-dose corticosteroids (methylprednisolone 1000 mg daily) were initiated. CSF-analysis displayed subtle pleocytosis, but revealed no signs of CNS infection (viral, bacterial and fungal) or meningeal involvement of the DLBCL. CT and MR imaging of the brain exhibited none of the pathological findings reported for ICANS [8] or CNS infection [9](Fig. 3c-d). After 5 days of high-dose methylprednisolone, the patient’s neurological status slowly improved, and corticosteroids could be tapered.
Partial response to Axicabtagene-Ciloleucel after 36 days according to Lugano criteria
While the patient’s initial clinical course was fraught with complications, CT staging performed at day 36 demonstrated a partial response to CAR T-cell therapy according to Lugano and Lyric criteria (Fig. 2a-g). This was particularly evident for the pleural manifestations of the underlying DLBCL, which was accompanied by an interval decrease in pleural effusions and subjective dyspnea (Fig. 2a-b). Multiple nodal sites including paraaortic (Fig. 2c-d) and parailiac lymph nodes (Fig. 2e-f) exhibited significant regression of tumor size (Fig. 2g). Moreover, the patient displayed splenic hypodensities consistent with either tumor tissue necrosis or infection-associated inflammatory changes (inset, Fig. 2f). These CT-morphologic findings were accompanied by a decrease of LDH levels (Fig. 2h).
Prolonged cytopenia lead to the development of severe neutropenic colitis and fatal fungal pneumonia
The patient presented with significant myelotoxicity and sustained transfusion dependency after CAR T-cell administration (Fig. 1c). The overall duration of profound neutropenia – defined as an ANC < 100/μl [10] – was 52 days. Because of the severity of ICANS, the clinicians chose to hold G-CSF during this time period due to concerns for risk of worsening toxicity [11].
While receiving broad anti-infectives (acyclovir, TMP/SMZ, posaconazole, meropenem), the patient developed breakthrough septic shock on day 24. He exhibited fever (39.5 °C), hypotension (70/30 mmHg), tachycardia (160/min), as well as lactic acidosis (lactate: 10.7 mmol/l). The patient was non-conversant, non-oriented, and was not able to localize symptoms. However, he had described epigastric tenderness and subtle changes in stool consistency and frequency on the previous day. As a result, abdominal CT imaging was obtained, which displayed severe pancolitis, as evidenced by pronounced mucosal thickening with edematous changes ranging from the ascending colon to the rectum (Fig. 3a-b). Labs were notable for an acute spike of serum inflammatory parameters (Il-6 > 500.000 pg/ml, CRP 5.7 mg/dl, Procalcitonin 11.2 ng/ml, Fig. 1d). Following ICU transfer, high-dose vasopressor support with norepinephrine was initiated together with volume resuscitation to maintain organ perfusion. Due to progressive loss of consciousness the patient was intubated and mechanically ventilated. To control the proinflammatory state, extracorporeal cytokine absorption (Cytosorb®) was performed, which resulted in a decrease of soluble inflammatory markers in the subsequent days. Arterial blood cultures were positive for vancomycin-resistant enterococci (VRE), and the antibiotic treatment was escalated to include linezolid along with meropenem (Fig. 1b). The ICU team transitioned antifungal prophylaxis from posaconazole to an echinocandine (micafungin 50 mg IV) due to ECG changes and concerns for drug interactions on day 24. Though he remained in critical condition, in the coming weeks his clinical condition stabilized and both the catecholamine rate and volume support could be reduced. To determine the origin of sustained myelosuppression, a bone marrow biopsy was obtained, which depicted a hypocellular marrow and severe aplasia affecting all hematopoietic lineages (Fig. 1e). On days 41 and 49, surveillance blood cultures were positive for Candida glabrata, a commensal fungal organism of human mucosal tissues [12] harboring an intrinsic azole resistance [13]. Susceptibility testing confirmed the azole-resistance of C. glabrata isolates. The antimycotic therapy was escalated from micafungin to liposomal amphotericin B. C. glabrata likely disseminated to the bloodstream secondary to the described gastrointestinal toxicity and was previously discovered on rectal swab (Fig. 1b) and fecal culture (day − 51).
Due to sustained neutropenia, BM aplasia and the availability of a suitable apheresis product, the CAR T-cell Taskforce proceeded with a stem cell boost of previously collected autologous CD34+ cells (3,1 × 106 cells) on day 46. The combination of a sudden rise in serum inflammatory markers and a strongly positive serum galactomannan (GM) assay on day 49 prompted diagnostic bronchoscopy, which revealed a diffuse infiltrate of alveolar and peri-bronchial tissue by Aspergillus fumigatus, consistent with fulminant invasive fungal pneumonia. Over the next week, the patient became increasingly hemodynamically unstable with poor peripheral oxygenation. Repeat bronchoscopy with bronchial lavage was positive for A. fumigatus and C. glabrata. After 50 days of G-CSF refractory aplasia, the autologous stem cells slowly engrafted leading to neutrophil recovery. However, this likely exacerbated the local inflammatory reaction in the lung, contributing to rapid deterioration of his respiratory status. Despite extensive supportive measures, the patient died on day 58 after CAR T-cell transfusion. Cause of death was confirmed by autopsy as invasive fungal pneumonia with multi-organ septic spread. Post-mortem examination revealed Candida spores in intestinal, colonic and rectal tissue. Of note, histopathologic BM analysis revealed signs of burgeoning hematopoietic regeneration (Fig. 1e).
Discussion and conclusions
Recent studies have shed light on the high incidence of prolonged and profound neutropenia after adoptive immunotherapy with CD19-specific CAR T-cells [1–3]. Clinical sequalae include severe infectious complications, which have emerged as the number one cause of long-term non-relapse mortality after CAR T-cell therapy [14]. In a seminal study, Hill and colleagues demonstrate that infectious complications are common with a cumulative incidence of 23% in the first 28 days after CAR T-cell transfusion and 14% between days 29–90. While bacterial infections were most common in the first month, viral infections – especially respiratory viruses – predominated after day 29, likely as a result of an impaired adaptive immune response due to B-cell aplasia [15]. Overall, most infections were mild to moderate and fatal infections were rare. Invasive mold infections were uncommon, ranging from 1 to 7% in CAR T-cell recipients [15–17]. In multivariate analyses, the use of systemic corticosteroids for the management of CRS or ICANS has emerged as a major risk factor of infection [18]. Certain inflammatory signatures – such as the “double peaks of IL-6” pattern observed in our patient – have been shown to confer an especially high risk of life-threatening infection [19].
This case highlights the combination of factors that precipitate a high risk of infectious complications in a CAR T-cell patient. First, the heavily pre-treated patient displayed B-cell aplasia and a diminished hematopoietic reserve (e.g. trilineage cytopenia) prior to lymphodepletion. Second, the patient developed classic complications of CAR T-cell therapy such as CRS and severe and prolonged ICANS, reflecting a pro-inflammatory state that represents an important risk factor for developing infections in CAR T-cell patients [16]. The subsequent application of high-dose corticosteroids impaired both innate and adaptive immunity [20]. Third, pancytopenia was profound, prolonged and not able to be reverted by growth factor support. Fourth, the patient had a history of infectious complications, including a course of fungal pneumonia 6 weeks prior to lymphodepletion, likely flaring up in the setting of the above three factors.
Our patient developed severe septic shock secondary to neutropenic colitis on day 24, highlighting the risk of a watch-and-wait approach to prolonged neutropenia after CAR T-cell therapy. A two-pronged approach to management appears prescient. On the one hand, measures to propagate hematopoietic recovery should be exhausted (causal therapy). This can range from G-CSF stimulation, to a trial of pulse-dose corticosteroids or anti-cytokine therapy (e.g. Anakinra, Tocilizumab), to a stem cell boost as a last resort in lymphoma patients who have undergone prior autologous stem cell transplantation. On the other hand, clinicians should be at high alert for infectious complications and adapt their infection surveillance and anti-infective prophylactic strategies accordingly. For example, therapeutic drug monitoring of posaconazole and meropenem levels may have revealed subtherapeutic dosing of these anti-infective agents in this patient [21]. The role of antifungal prophylaxis in the CAR T-cell patient remains inconclusive. Adequately powered studies addressing the duration of neutropenia after CAR T-cell therapy, and potential clinical determinants of invasive fungal infections, will be critical to gauge the benefit of antifungal prophylaxis in this patient collective.
Candida species are a leading cause of fungus-associated morbidity and mortality in severely immunocompromised patients [21]. On day 41, this patient developed breakthrough C. glabrata Candidemia on micafungin, in the setting of both underlying colonization and neutropenic colitis. A recent report implicated the gastrointestinal tract as major source of echinocandin drug resistance in a murine model of C. glabrata colonization and systemic dissemination [22]. Of note, breakthrough Candida infections on micafungin may occur at the employed dose level (50 mg/day IV), suggesting that this dose may have been inadequate to prevent subsequent Candidemia [23]. Though cases of C. glabrata colitis are extremely rare [24], an opportunistic infection could not be ruled out given that C. glabrata infiltrates were discovered in enteral and colonic mucosal tissue on post-mortem examination. Importantly, the patients’ clinical status deteriorated only after the stem cell boost resulted in signs of hematopoietic recovery. The paradoxical worsening of the pulmonary A. fumigatus infection is consistent with immune reconstitution inflammatory syndrome (IRIS), which has been previously described for HIV/AIDS [25] and for severely neutropenic patients with IPA [26]. In conclusion, this case emphasizes that infectious complications secondary to prolonged cytopenia influence non-relapse mortality after CAR T-cell therapy.
Abbreviations
ALCAbsolute Lymphocyte Count
ANCAbsolute Neutrophil Count
BMBone Marrow
CARChimeric antigen receptor
CBCComplete Blood Count
CRSCytokine release syndrome
CTCAECommon Terminology Criteria for Adverse Events
DLBCLDiffuse large B-cell lymphoma
FFPFresh frozen plasma
FLAIRFluid-attenuated inversion recovery
Flu/CyFludarabine/Cyclophosphamide
G-CSFGranulocyte colony stimulating factor
GIGastrointestinal
GMGalactomannan
HSPCsHematopoietic stem and progenitor cells
ICANSImmune effector cell-associated neurotoxicity syndrome
ICE-scoreImmune Effector Cell-associated Encephalopathy score
ICUIntensive care unit
IPAInvasive pulmonary aspergillosis
LDHLactate Dehydrogenase
LYRICLymphoma response to immunomodulatory therapy criteria
MDRDModification of Diet in Renal Disease
MPOMyeloperoxidase
PASPeriodic acid-Schiff
PBSCPeripheral Blood Stem Cell
VREVancomycin-resistant Enterococcus
WBCWhite Blood Count
Publisher’s Note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
Acknowledgements
Not applicable.
Authors’ contributions
The original manuscript was written by KR. KR and WGK prepared the figures. MR performed the histological examination of the bone marrow. MS reviewed and edited the manuscript. The other authors (VB1, VB2, CS, PK, FS, KD, LvB, JS, OW, MD, MvBB) contributed to patient management and participated in drafting and editing the manuscript. All authors read and approved the final manuscript.
Funding
Not applicable. Open Access funding enabled and organized by Projekt DEAL.
Availability of data and materials
The authors did not use any database, software, or tools for the writing of this manuscript.
Ethics approval and consent to participate
The authors obtained consent from the deceased patient’s next-of-kin to participate.
Consent for publication
Written informed consent was obtained from the patient’s next-of-kin for publication of this Case report and any accompanying images. A copy of the written consent is available for review by the Editor of this journal.
Competing interests
The authors declare that they have no competing interests related with this case report. | Recovered | ReactionOutcome | CC BY | 33509115 | 18,947,434 | 2021-01-28 |
What was the outcome of reaction 'Pneumonia fungal'? | Severe Candida glabrata pancolitis and fatal Aspergillus fumigatus pulmonary infection in the setting of bone marrow aplasia after CD19-directed CAR T-cell therapy - a case report.
BACKGROUND
Prolonged myelosuppression following CD19-directed CAR T-cell transfusion represents an important, yet underreported, adverse event. The resulting neutropenia and multifactorial immunosuppression can facilitate severe infectious complications.
METHODS
We describe the clinical course of a 59-year-old patient with relapsed/refractory DLBCL who received Axicabtagene-Ciloleucel (Axi-cel). The patient developed ASTCT grade I CRS and grade IV ICANS, necessitating admission to the neurological ICU and prolonged application of high-dose corticosteroids and other immunosuppressive agents. Importantly, neutropenia was profound (ANC < 100/μl), G-CSF-refractory, and prolonged, lasting more than 50 days. The patient developed severe septic shock 3 weeks after CAR transfusion while receiving anti-fungal prophylaxis with micafungin. His clinical status stabilized with broad anti-infective treatment and intensive supportive measures. An autologous stem cell backup was employed on day 46 to support hematopoietic recovery. Although the counts of the patient eventually started to recover, he developed an invasive pulmonary aspergillosis, which ultimately lead to respiratory failure and death. Postmortem examination revealed signs of Candida glabrata pancolitis.
CONCLUSIONS
This case highlights the increased risk for fatal infectious complications in patients who present with profound and prolonged cytopenia after CAR T-cell therapy. We describe a rare case of C. glabrata pancolitis associated with multifactorial immunosuppression. Although our patient succumbed to a fatal fungal infection, autologous stem cell boost was able to spur hematopoiesis and may represent an important therapeutic strategy for DLBCL patients with CAR T-cell associated bone marrow aplasia who have underwent prior stem cell harvest.
Background
When CD19-directed Chimeric Antigen Receptor (CAR) T-cell therapies were first introduced into the clinical setting, a set of distinctive side effects were observed, including Cytokine Release Syndrome (CRS) and immune effector cell-associated neurotoxicity syndrome (ICANS). As these treatments transition from large clinical trials to real-world implementation, new nuances of the side effect spectrum have emerged. This includes the observation that patients can present not only with grade 3–4 cytopenia (CTCAE v5.0), but also a syndrome of persistent cytopenia after CAR T-cell transfusion [1, 2]. Hematologic toxicity is common with one study demonstrating that neutropenia, thrombocytopenia and anemia occur in 94, 80 and 51% of patients respectively [3]. Risk factors for hematotoxicity include CRS grade, baseline cytopenia, and prior allogeneic stem cell transplantation within the last year [2, 3]. The fact that baseline hematopoietic reserve contributes to cytopenia in CAR T-cell patients may explain the variability in the incidence of hematoxicity in the real-world setting compared to the large registration trials, which set stringent hematologic exclusion criteria [4, 5]. The clinical utility of therapeutic rescue strategies that mitigate the risk of infectious complications secondary to long-term bone marrow (BM) aplasia, such as early autologous stem cell boost or Eltrombopag, remains unknown. Moreover, the relative paucity of reports concerning severe and life-threatening infections in the reported CD19-directed CAR T-cell trials necessitates the presentation of distinctive clinical courses that underline the risks of persistent cytopenia after CAR T-cell therapy in a real-world setting.
Case presentation
The 59-year-old male patient was initially diagnosed with stage IIIA follicular lymphoma in January 2018, which transformed to germinal center B-cell like DLBCL in October of the same year. Refractory to multiple cycles of Rituximab-based immunochemotherapy (Fig. 1a), the patient underwent leukapheresis for CAR T-cell therapy in April 2019. The patient experienced significant lymphoma progression during the manufacturing process of Axicabtagene ciloleucel (Axi-cel), manifesting itself in the form of malignant pleural effusions and progressive lymphadenopathy (Fig. 2a,c,e). In the six-week period between leukapheresis and lymphodepletion, the patient remained severely neutropenic after R-CHOP and developed possible invasive fungal disease (IFD) [6] (Fig. 3e) as well as E. coli septicemia secondary to a urinary tract infection. These infections were treated successfully with liposomal amphotericin B and piperacillin/tazobactam. Prior to lymphodepletion (D-5), the patient presented with an ECOG performance status of 1, intact renal and liver function, while observing residually depressed blood counts (WBC 1270/μl, ANC 700/μl, ALC 390/μl, Hemoglobin 7.2 g/dl, Platelets 20 G/l). BM histopathology showed a hypocellular marrow with no evidence of lymphoma infiltration. Analysis of lymphocyte subpopulations demonstrated severe B-cell aplasia and decreased absolute CD4+ (84/μl) and CD8+ (271/μl) counts. His anti-infective prophylaxis consisted of a combination of acyclovir, sulfamethoxazole/trimethoprim (TMP/SMZ), and posaconazole. The fludarabine/cyclophosphamide lympho-preparative regimen was applied on days − 5 to − 3 according to the provider’s protocol, followed by CAR T-cell transfusion on day 0.
Fig. 1 Overview of CAR T-cell mediated hematotoxicity and infectious complications. a Treatment course prior to CAR T-cell therapy. b Timeline of infectious complications during CAR T-cell treatment course. Positive microbiologic culture results are underlined. Bottom: Overview of utilized anti-infectives with the respective bars displaying the length of treatment. P/T = piperacillin/tazobactam, Ami = amikacin, Mero = meropenem, Vanco = vancomycin, Line = linezolid, Posa = posaconazole (p.o.), Mica = micafungin (i.v.), Amb = liposomal amphotericin B. The patient also received prophylactic acyclovir and sulfamethoxazole/trimethoprim (TMP/SMZ) during treatment. c Complete Blood Count (CBC) timeline. ANC (blue), platelet count (green), Hemoglobin (red). Transfusion events (green: platelet transfusion, red: pRBC transfusion) and G-CSF support (blue bar) are integrated in the curve. d Dynamics of Serum Inflammatory Markers. Infectious complications are superimposed above the graph. e Histopathologic analysis of BM biopsies demonstrating severe BM aplasia 1 month after CAR T-cell transfusion (Day 32, upper panel) and evidence of recovering hematopoiesis following autologous stem cell transfer (Autopsy, lower panel). Immunohistochemical staining for myeloperoxidase (= MPO) highlighting strong activation of myelopoiesis (right panel)
Fig. 2 Radiographic evidence of partial response to Axi-cel after 36 days. Contrast-enhanced CT abdomen (axial view) displaying pleural manifestations before (a) and after (b) CAR T-cell treatment. Involved paraaortic lymph nodes (red arrows) demonstrate an interval decrease in size (c-d, e-f). The inset of panel F depicts splenic hypodensities consistent with necrosis of tumor tissue secondary to immune therapy and a reduction of splenomegaly. G Graphical depiction of response over time. Tumor extent was quantified as the sum of the product of perpendicular diameters according to Lugano criteria over 3 time points and is graphed on the y-axis. H Timeline of LDH levels (U/l). The increase in LDH levels at day 25 correlated with the gastrointestinal toxicity and liver dysfunction
Fig. 3 Multi-organ toxicity secondary to CD19-directed CAR T-cell therapy. a Contrast-enhanced CT abdomen demonstrating a non-inflamed baseline state of GI mucosal tissue prior to CAR T therapy. b Panmural swelling of the sigma (left panel), ascending colon (middle panel), and stomach. c Non-pathologic CT of the brain. d Axial FLAIR-weighted (left), T1-weighted contrast-enhanced (middle), and diffusion-weighted (right) MRI displaying no evidence of cerebral edema, white matter lesions, diffusion restriction, microbleeds, meningeal enhancement or contrast enhancing lesions. e High-resolution CT thorax with bilateral fungal infiltrates observing the typical halo configuration 6 weeks prior to CAR T-cell transfusion. f On day − 3 the right-sided infiltrates have decreased in size. The left lung is collapsed due to malignant pleural effusion. g Lung parenchyma exhibiting an infiltration of non-dimorphic blastoconidial morphology consistent with Candida glabrata. h PAS staining of a lung specimen highlights septated hiphae and acute-angle branching, features consistent of with aspergillus infection
During lymphodepletion the patient developed an upper respiratory infection, presenting with a non-productive cough and a sputum culture positive for Bordetella bronchiseptica, which resolved clinically after antibiotic treatment with piperacillin/tazobactam. On day 7, the patient developed fever with a stable cardiopulmonary function and concomitant IL-6 rise (Fig. 1d), which was classified as CRS grade I according to ASTCT consensus grading [7] in the absence of positive blood cultures and other foci. Due to persistent fever refractory to antipyretic treatment, four total doses of tocilizumab (8 mg/kg) were applied over 36 h. Starting on day 9, the patient deteriorated neurologically with a depressed state of consciousness prompting the diagnosis of grade IV ICANS. The patient was transferred to the neurological ICU, and high-dose corticosteroids (methylprednisolone 1000 mg daily) were initiated. CSF-analysis displayed subtle pleocytosis, but revealed no signs of CNS infection (viral, bacterial and fungal) or meningeal involvement of the DLBCL. CT and MR imaging of the brain exhibited none of the pathological findings reported for ICANS [8] or CNS infection [9](Fig. 3c-d). After 5 days of high-dose methylprednisolone, the patient’s neurological status slowly improved, and corticosteroids could be tapered.
Partial response to Axicabtagene-Ciloleucel after 36 days according to Lugano criteria
While the patient’s initial clinical course was fraught with complications, CT staging performed at day 36 demonstrated a partial response to CAR T-cell therapy according to Lugano and Lyric criteria (Fig. 2a-g). This was particularly evident for the pleural manifestations of the underlying DLBCL, which was accompanied by an interval decrease in pleural effusions and subjective dyspnea (Fig. 2a-b). Multiple nodal sites including paraaortic (Fig. 2c-d) and parailiac lymph nodes (Fig. 2e-f) exhibited significant regression of tumor size (Fig. 2g). Moreover, the patient displayed splenic hypodensities consistent with either tumor tissue necrosis or infection-associated inflammatory changes (inset, Fig. 2f). These CT-morphologic findings were accompanied by a decrease of LDH levels (Fig. 2h).
Prolonged cytopenia lead to the development of severe neutropenic colitis and fatal fungal pneumonia
The patient presented with significant myelotoxicity and sustained transfusion dependency after CAR T-cell administration (Fig. 1c). The overall duration of profound neutropenia – defined as an ANC < 100/μl [10] – was 52 days. Because of the severity of ICANS, the clinicians chose to hold G-CSF during this time period due to concerns for risk of worsening toxicity [11].
While receiving broad anti-infectives (acyclovir, TMP/SMZ, posaconazole, meropenem), the patient developed breakthrough septic shock on day 24. He exhibited fever (39.5 °C), hypotension (70/30 mmHg), tachycardia (160/min), as well as lactic acidosis (lactate: 10.7 mmol/l). The patient was non-conversant, non-oriented, and was not able to localize symptoms. However, he had described epigastric tenderness and subtle changes in stool consistency and frequency on the previous day. As a result, abdominal CT imaging was obtained, which displayed severe pancolitis, as evidenced by pronounced mucosal thickening with edematous changes ranging from the ascending colon to the rectum (Fig. 3a-b). Labs were notable for an acute spike of serum inflammatory parameters (Il-6 > 500.000 pg/ml, CRP 5.7 mg/dl, Procalcitonin 11.2 ng/ml, Fig. 1d). Following ICU transfer, high-dose vasopressor support with norepinephrine was initiated together with volume resuscitation to maintain organ perfusion. Due to progressive loss of consciousness the patient was intubated and mechanically ventilated. To control the proinflammatory state, extracorporeal cytokine absorption (Cytosorb®) was performed, which resulted in a decrease of soluble inflammatory markers in the subsequent days. Arterial blood cultures were positive for vancomycin-resistant enterococci (VRE), and the antibiotic treatment was escalated to include linezolid along with meropenem (Fig. 1b). The ICU team transitioned antifungal prophylaxis from posaconazole to an echinocandine (micafungin 50 mg IV) due to ECG changes and concerns for drug interactions on day 24. Though he remained in critical condition, in the coming weeks his clinical condition stabilized and both the catecholamine rate and volume support could be reduced. To determine the origin of sustained myelosuppression, a bone marrow biopsy was obtained, which depicted a hypocellular marrow and severe aplasia affecting all hematopoietic lineages (Fig. 1e). On days 41 and 49, surveillance blood cultures were positive for Candida glabrata, a commensal fungal organism of human mucosal tissues [12] harboring an intrinsic azole resistance [13]. Susceptibility testing confirmed the azole-resistance of C. glabrata isolates. The antimycotic therapy was escalated from micafungin to liposomal amphotericin B. C. glabrata likely disseminated to the bloodstream secondary to the described gastrointestinal toxicity and was previously discovered on rectal swab (Fig. 1b) and fecal culture (day − 51).
Due to sustained neutropenia, BM aplasia and the availability of a suitable apheresis product, the CAR T-cell Taskforce proceeded with a stem cell boost of previously collected autologous CD34+ cells (3,1 × 106 cells) on day 46. The combination of a sudden rise in serum inflammatory markers and a strongly positive serum galactomannan (GM) assay on day 49 prompted diagnostic bronchoscopy, which revealed a diffuse infiltrate of alveolar and peri-bronchial tissue by Aspergillus fumigatus, consistent with fulminant invasive fungal pneumonia. Over the next week, the patient became increasingly hemodynamically unstable with poor peripheral oxygenation. Repeat bronchoscopy with bronchial lavage was positive for A. fumigatus and C. glabrata. After 50 days of G-CSF refractory aplasia, the autologous stem cells slowly engrafted leading to neutrophil recovery. However, this likely exacerbated the local inflammatory reaction in the lung, contributing to rapid deterioration of his respiratory status. Despite extensive supportive measures, the patient died on day 58 after CAR T-cell transfusion. Cause of death was confirmed by autopsy as invasive fungal pneumonia with multi-organ septic spread. Post-mortem examination revealed Candida spores in intestinal, colonic and rectal tissue. Of note, histopathologic BM analysis revealed signs of burgeoning hematopoietic regeneration (Fig. 1e).
Discussion and conclusions
Recent studies have shed light on the high incidence of prolonged and profound neutropenia after adoptive immunotherapy with CD19-specific CAR T-cells [1–3]. Clinical sequalae include severe infectious complications, which have emerged as the number one cause of long-term non-relapse mortality after CAR T-cell therapy [14]. In a seminal study, Hill and colleagues demonstrate that infectious complications are common with a cumulative incidence of 23% in the first 28 days after CAR T-cell transfusion and 14% between days 29–90. While bacterial infections were most common in the first month, viral infections – especially respiratory viruses – predominated after day 29, likely as a result of an impaired adaptive immune response due to B-cell aplasia [15]. Overall, most infections were mild to moderate and fatal infections were rare. Invasive mold infections were uncommon, ranging from 1 to 7% in CAR T-cell recipients [15–17]. In multivariate analyses, the use of systemic corticosteroids for the management of CRS or ICANS has emerged as a major risk factor of infection [18]. Certain inflammatory signatures – such as the “double peaks of IL-6” pattern observed in our patient – have been shown to confer an especially high risk of life-threatening infection [19].
This case highlights the combination of factors that precipitate a high risk of infectious complications in a CAR T-cell patient. First, the heavily pre-treated patient displayed B-cell aplasia and a diminished hematopoietic reserve (e.g. trilineage cytopenia) prior to lymphodepletion. Second, the patient developed classic complications of CAR T-cell therapy such as CRS and severe and prolonged ICANS, reflecting a pro-inflammatory state that represents an important risk factor for developing infections in CAR T-cell patients [16]. The subsequent application of high-dose corticosteroids impaired both innate and adaptive immunity [20]. Third, pancytopenia was profound, prolonged and not able to be reverted by growth factor support. Fourth, the patient had a history of infectious complications, including a course of fungal pneumonia 6 weeks prior to lymphodepletion, likely flaring up in the setting of the above three factors.
Our patient developed severe septic shock secondary to neutropenic colitis on day 24, highlighting the risk of a watch-and-wait approach to prolonged neutropenia after CAR T-cell therapy. A two-pronged approach to management appears prescient. On the one hand, measures to propagate hematopoietic recovery should be exhausted (causal therapy). This can range from G-CSF stimulation, to a trial of pulse-dose corticosteroids or anti-cytokine therapy (e.g. Anakinra, Tocilizumab), to a stem cell boost as a last resort in lymphoma patients who have undergone prior autologous stem cell transplantation. On the other hand, clinicians should be at high alert for infectious complications and adapt their infection surveillance and anti-infective prophylactic strategies accordingly. For example, therapeutic drug monitoring of posaconazole and meropenem levels may have revealed subtherapeutic dosing of these anti-infective agents in this patient [21]. The role of antifungal prophylaxis in the CAR T-cell patient remains inconclusive. Adequately powered studies addressing the duration of neutropenia after CAR T-cell therapy, and potential clinical determinants of invasive fungal infections, will be critical to gauge the benefit of antifungal prophylaxis in this patient collective.
Candida species are a leading cause of fungus-associated morbidity and mortality in severely immunocompromised patients [21]. On day 41, this patient developed breakthrough C. glabrata Candidemia on micafungin, in the setting of both underlying colonization and neutropenic colitis. A recent report implicated the gastrointestinal tract as major source of echinocandin drug resistance in a murine model of C. glabrata colonization and systemic dissemination [22]. Of note, breakthrough Candida infections on micafungin may occur at the employed dose level (50 mg/day IV), suggesting that this dose may have been inadequate to prevent subsequent Candidemia [23]. Though cases of C. glabrata colitis are extremely rare [24], an opportunistic infection could not be ruled out given that C. glabrata infiltrates were discovered in enteral and colonic mucosal tissue on post-mortem examination. Importantly, the patients’ clinical status deteriorated only after the stem cell boost resulted in signs of hematopoietic recovery. The paradoxical worsening of the pulmonary A. fumigatus infection is consistent with immune reconstitution inflammatory syndrome (IRIS), which has been previously described for HIV/AIDS [25] and for severely neutropenic patients with IPA [26]. In conclusion, this case emphasizes that infectious complications secondary to prolonged cytopenia influence non-relapse mortality after CAR T-cell therapy.
Abbreviations
ALCAbsolute Lymphocyte Count
ANCAbsolute Neutrophil Count
BMBone Marrow
CARChimeric antigen receptor
CBCComplete Blood Count
CRSCytokine release syndrome
CTCAECommon Terminology Criteria for Adverse Events
DLBCLDiffuse large B-cell lymphoma
FFPFresh frozen plasma
FLAIRFluid-attenuated inversion recovery
Flu/CyFludarabine/Cyclophosphamide
G-CSFGranulocyte colony stimulating factor
GIGastrointestinal
GMGalactomannan
HSPCsHematopoietic stem and progenitor cells
ICANSImmune effector cell-associated neurotoxicity syndrome
ICE-scoreImmune Effector Cell-associated Encephalopathy score
ICUIntensive care unit
IPAInvasive pulmonary aspergillosis
LDHLactate Dehydrogenase
LYRICLymphoma response to immunomodulatory therapy criteria
MDRDModification of Diet in Renal Disease
MPOMyeloperoxidase
PASPeriodic acid-Schiff
PBSCPeripheral Blood Stem Cell
VREVancomycin-resistant Enterococcus
WBCWhite Blood Count
Publisher’s Note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
Acknowledgements
Not applicable.
Authors’ contributions
The original manuscript was written by KR. KR and WGK prepared the figures. MR performed the histological examination of the bone marrow. MS reviewed and edited the manuscript. The other authors (VB1, VB2, CS, PK, FS, KD, LvB, JS, OW, MD, MvBB) contributed to patient management and participated in drafting and editing the manuscript. All authors read and approved the final manuscript.
Funding
Not applicable. Open Access funding enabled and organized by Projekt DEAL.
Availability of data and materials
The authors did not use any database, software, or tools for the writing of this manuscript.
Ethics approval and consent to participate
The authors obtained consent from the deceased patient’s next-of-kin to participate.
Consent for publication
Written informed consent was obtained from the patient’s next-of-kin for publication of this Case report and any accompanying images. A copy of the written consent is available for review by the Editor of this journal.
Competing interests
The authors declare that they have no competing interests related with this case report. | Fatal | ReactionOutcome | CC BY | 33509115 | 18,947,434 | 2021-01-28 |
What was the outcome of reaction 'Septic shock'? | Severe Candida glabrata pancolitis and fatal Aspergillus fumigatus pulmonary infection in the setting of bone marrow aplasia after CD19-directed CAR T-cell therapy - a case report.
BACKGROUND
Prolonged myelosuppression following CD19-directed CAR T-cell transfusion represents an important, yet underreported, adverse event. The resulting neutropenia and multifactorial immunosuppression can facilitate severe infectious complications.
METHODS
We describe the clinical course of a 59-year-old patient with relapsed/refractory DLBCL who received Axicabtagene-Ciloleucel (Axi-cel). The patient developed ASTCT grade I CRS and grade IV ICANS, necessitating admission to the neurological ICU and prolonged application of high-dose corticosteroids and other immunosuppressive agents. Importantly, neutropenia was profound (ANC < 100/μl), G-CSF-refractory, and prolonged, lasting more than 50 days. The patient developed severe septic shock 3 weeks after CAR transfusion while receiving anti-fungal prophylaxis with micafungin. His clinical status stabilized with broad anti-infective treatment and intensive supportive measures. An autologous stem cell backup was employed on day 46 to support hematopoietic recovery. Although the counts of the patient eventually started to recover, he developed an invasive pulmonary aspergillosis, which ultimately lead to respiratory failure and death. Postmortem examination revealed signs of Candida glabrata pancolitis.
CONCLUSIONS
This case highlights the increased risk for fatal infectious complications in patients who present with profound and prolonged cytopenia after CAR T-cell therapy. We describe a rare case of C. glabrata pancolitis associated with multifactorial immunosuppression. Although our patient succumbed to a fatal fungal infection, autologous stem cell boost was able to spur hematopoiesis and may represent an important therapeutic strategy for DLBCL patients with CAR T-cell associated bone marrow aplasia who have underwent prior stem cell harvest.
Background
When CD19-directed Chimeric Antigen Receptor (CAR) T-cell therapies were first introduced into the clinical setting, a set of distinctive side effects were observed, including Cytokine Release Syndrome (CRS) and immune effector cell-associated neurotoxicity syndrome (ICANS). As these treatments transition from large clinical trials to real-world implementation, new nuances of the side effect spectrum have emerged. This includes the observation that patients can present not only with grade 3–4 cytopenia (CTCAE v5.0), but also a syndrome of persistent cytopenia after CAR T-cell transfusion [1, 2]. Hematologic toxicity is common with one study demonstrating that neutropenia, thrombocytopenia and anemia occur in 94, 80 and 51% of patients respectively [3]. Risk factors for hematotoxicity include CRS grade, baseline cytopenia, and prior allogeneic stem cell transplantation within the last year [2, 3]. The fact that baseline hematopoietic reserve contributes to cytopenia in CAR T-cell patients may explain the variability in the incidence of hematoxicity in the real-world setting compared to the large registration trials, which set stringent hematologic exclusion criteria [4, 5]. The clinical utility of therapeutic rescue strategies that mitigate the risk of infectious complications secondary to long-term bone marrow (BM) aplasia, such as early autologous stem cell boost or Eltrombopag, remains unknown. Moreover, the relative paucity of reports concerning severe and life-threatening infections in the reported CD19-directed CAR T-cell trials necessitates the presentation of distinctive clinical courses that underline the risks of persistent cytopenia after CAR T-cell therapy in a real-world setting.
Case presentation
The 59-year-old male patient was initially diagnosed with stage IIIA follicular lymphoma in January 2018, which transformed to germinal center B-cell like DLBCL in October of the same year. Refractory to multiple cycles of Rituximab-based immunochemotherapy (Fig. 1a), the patient underwent leukapheresis for CAR T-cell therapy in April 2019. The patient experienced significant lymphoma progression during the manufacturing process of Axicabtagene ciloleucel (Axi-cel), manifesting itself in the form of malignant pleural effusions and progressive lymphadenopathy (Fig. 2a,c,e). In the six-week period between leukapheresis and lymphodepletion, the patient remained severely neutropenic after R-CHOP and developed possible invasive fungal disease (IFD) [6] (Fig. 3e) as well as E. coli septicemia secondary to a urinary tract infection. These infections were treated successfully with liposomal amphotericin B and piperacillin/tazobactam. Prior to lymphodepletion (D-5), the patient presented with an ECOG performance status of 1, intact renal and liver function, while observing residually depressed blood counts (WBC 1270/μl, ANC 700/μl, ALC 390/μl, Hemoglobin 7.2 g/dl, Platelets 20 G/l). BM histopathology showed a hypocellular marrow with no evidence of lymphoma infiltration. Analysis of lymphocyte subpopulations demonstrated severe B-cell aplasia and decreased absolute CD4+ (84/μl) and CD8+ (271/μl) counts. His anti-infective prophylaxis consisted of a combination of acyclovir, sulfamethoxazole/trimethoprim (TMP/SMZ), and posaconazole. The fludarabine/cyclophosphamide lympho-preparative regimen was applied on days − 5 to − 3 according to the provider’s protocol, followed by CAR T-cell transfusion on day 0.
Fig. 1 Overview of CAR T-cell mediated hematotoxicity and infectious complications. a Treatment course prior to CAR T-cell therapy. b Timeline of infectious complications during CAR T-cell treatment course. Positive microbiologic culture results are underlined. Bottom: Overview of utilized anti-infectives with the respective bars displaying the length of treatment. P/T = piperacillin/tazobactam, Ami = amikacin, Mero = meropenem, Vanco = vancomycin, Line = linezolid, Posa = posaconazole (p.o.), Mica = micafungin (i.v.), Amb = liposomal amphotericin B. The patient also received prophylactic acyclovir and sulfamethoxazole/trimethoprim (TMP/SMZ) during treatment. c Complete Blood Count (CBC) timeline. ANC (blue), platelet count (green), Hemoglobin (red). Transfusion events (green: platelet transfusion, red: pRBC transfusion) and G-CSF support (blue bar) are integrated in the curve. d Dynamics of Serum Inflammatory Markers. Infectious complications are superimposed above the graph. e Histopathologic analysis of BM biopsies demonstrating severe BM aplasia 1 month after CAR T-cell transfusion (Day 32, upper panel) and evidence of recovering hematopoiesis following autologous stem cell transfer (Autopsy, lower panel). Immunohistochemical staining for myeloperoxidase (= MPO) highlighting strong activation of myelopoiesis (right panel)
Fig. 2 Radiographic evidence of partial response to Axi-cel after 36 days. Contrast-enhanced CT abdomen (axial view) displaying pleural manifestations before (a) and after (b) CAR T-cell treatment. Involved paraaortic lymph nodes (red arrows) demonstrate an interval decrease in size (c-d, e-f). The inset of panel F depicts splenic hypodensities consistent with necrosis of tumor tissue secondary to immune therapy and a reduction of splenomegaly. G Graphical depiction of response over time. Tumor extent was quantified as the sum of the product of perpendicular diameters according to Lugano criteria over 3 time points and is graphed on the y-axis. H Timeline of LDH levels (U/l). The increase in LDH levels at day 25 correlated with the gastrointestinal toxicity and liver dysfunction
Fig. 3 Multi-organ toxicity secondary to CD19-directed CAR T-cell therapy. a Contrast-enhanced CT abdomen demonstrating a non-inflamed baseline state of GI mucosal tissue prior to CAR T therapy. b Panmural swelling of the sigma (left panel), ascending colon (middle panel), and stomach. c Non-pathologic CT of the brain. d Axial FLAIR-weighted (left), T1-weighted contrast-enhanced (middle), and diffusion-weighted (right) MRI displaying no evidence of cerebral edema, white matter lesions, diffusion restriction, microbleeds, meningeal enhancement or contrast enhancing lesions. e High-resolution CT thorax with bilateral fungal infiltrates observing the typical halo configuration 6 weeks prior to CAR T-cell transfusion. f On day − 3 the right-sided infiltrates have decreased in size. The left lung is collapsed due to malignant pleural effusion. g Lung parenchyma exhibiting an infiltration of non-dimorphic blastoconidial morphology consistent with Candida glabrata. h PAS staining of a lung specimen highlights septated hiphae and acute-angle branching, features consistent of with aspergillus infection
During lymphodepletion the patient developed an upper respiratory infection, presenting with a non-productive cough and a sputum culture positive for Bordetella bronchiseptica, which resolved clinically after antibiotic treatment with piperacillin/tazobactam. On day 7, the patient developed fever with a stable cardiopulmonary function and concomitant IL-6 rise (Fig. 1d), which was classified as CRS grade I according to ASTCT consensus grading [7] in the absence of positive blood cultures and other foci. Due to persistent fever refractory to antipyretic treatment, four total doses of tocilizumab (8 mg/kg) were applied over 36 h. Starting on day 9, the patient deteriorated neurologically with a depressed state of consciousness prompting the diagnosis of grade IV ICANS. The patient was transferred to the neurological ICU, and high-dose corticosteroids (methylprednisolone 1000 mg daily) were initiated. CSF-analysis displayed subtle pleocytosis, but revealed no signs of CNS infection (viral, bacterial and fungal) or meningeal involvement of the DLBCL. CT and MR imaging of the brain exhibited none of the pathological findings reported for ICANS [8] or CNS infection [9](Fig. 3c-d). After 5 days of high-dose methylprednisolone, the patient’s neurological status slowly improved, and corticosteroids could be tapered.
Partial response to Axicabtagene-Ciloleucel after 36 days according to Lugano criteria
While the patient’s initial clinical course was fraught with complications, CT staging performed at day 36 demonstrated a partial response to CAR T-cell therapy according to Lugano and Lyric criteria (Fig. 2a-g). This was particularly evident for the pleural manifestations of the underlying DLBCL, which was accompanied by an interval decrease in pleural effusions and subjective dyspnea (Fig. 2a-b). Multiple nodal sites including paraaortic (Fig. 2c-d) and parailiac lymph nodes (Fig. 2e-f) exhibited significant regression of tumor size (Fig. 2g). Moreover, the patient displayed splenic hypodensities consistent with either tumor tissue necrosis or infection-associated inflammatory changes (inset, Fig. 2f). These CT-morphologic findings were accompanied by a decrease of LDH levels (Fig. 2h).
Prolonged cytopenia lead to the development of severe neutropenic colitis and fatal fungal pneumonia
The patient presented with significant myelotoxicity and sustained transfusion dependency after CAR T-cell administration (Fig. 1c). The overall duration of profound neutropenia – defined as an ANC < 100/μl [10] – was 52 days. Because of the severity of ICANS, the clinicians chose to hold G-CSF during this time period due to concerns for risk of worsening toxicity [11].
While receiving broad anti-infectives (acyclovir, TMP/SMZ, posaconazole, meropenem), the patient developed breakthrough septic shock on day 24. He exhibited fever (39.5 °C), hypotension (70/30 mmHg), tachycardia (160/min), as well as lactic acidosis (lactate: 10.7 mmol/l). The patient was non-conversant, non-oriented, and was not able to localize symptoms. However, he had described epigastric tenderness and subtle changes in stool consistency and frequency on the previous day. As a result, abdominal CT imaging was obtained, which displayed severe pancolitis, as evidenced by pronounced mucosal thickening with edematous changes ranging from the ascending colon to the rectum (Fig. 3a-b). Labs were notable for an acute spike of serum inflammatory parameters (Il-6 > 500.000 pg/ml, CRP 5.7 mg/dl, Procalcitonin 11.2 ng/ml, Fig. 1d). Following ICU transfer, high-dose vasopressor support with norepinephrine was initiated together with volume resuscitation to maintain organ perfusion. Due to progressive loss of consciousness the patient was intubated and mechanically ventilated. To control the proinflammatory state, extracorporeal cytokine absorption (Cytosorb®) was performed, which resulted in a decrease of soluble inflammatory markers in the subsequent days. Arterial blood cultures were positive for vancomycin-resistant enterococci (VRE), and the antibiotic treatment was escalated to include linezolid along with meropenem (Fig. 1b). The ICU team transitioned antifungal prophylaxis from posaconazole to an echinocandine (micafungin 50 mg IV) due to ECG changes and concerns for drug interactions on day 24. Though he remained in critical condition, in the coming weeks his clinical condition stabilized and both the catecholamine rate and volume support could be reduced. To determine the origin of sustained myelosuppression, a bone marrow biopsy was obtained, which depicted a hypocellular marrow and severe aplasia affecting all hematopoietic lineages (Fig. 1e). On days 41 and 49, surveillance blood cultures were positive for Candida glabrata, a commensal fungal organism of human mucosal tissues [12] harboring an intrinsic azole resistance [13]. Susceptibility testing confirmed the azole-resistance of C. glabrata isolates. The antimycotic therapy was escalated from micafungin to liposomal amphotericin B. C. glabrata likely disseminated to the bloodstream secondary to the described gastrointestinal toxicity and was previously discovered on rectal swab (Fig. 1b) and fecal culture (day − 51).
Due to sustained neutropenia, BM aplasia and the availability of a suitable apheresis product, the CAR T-cell Taskforce proceeded with a stem cell boost of previously collected autologous CD34+ cells (3,1 × 106 cells) on day 46. The combination of a sudden rise in serum inflammatory markers and a strongly positive serum galactomannan (GM) assay on day 49 prompted diagnostic bronchoscopy, which revealed a diffuse infiltrate of alveolar and peri-bronchial tissue by Aspergillus fumigatus, consistent with fulminant invasive fungal pneumonia. Over the next week, the patient became increasingly hemodynamically unstable with poor peripheral oxygenation. Repeat bronchoscopy with bronchial lavage was positive for A. fumigatus and C. glabrata. After 50 days of G-CSF refractory aplasia, the autologous stem cells slowly engrafted leading to neutrophil recovery. However, this likely exacerbated the local inflammatory reaction in the lung, contributing to rapid deterioration of his respiratory status. Despite extensive supportive measures, the patient died on day 58 after CAR T-cell transfusion. Cause of death was confirmed by autopsy as invasive fungal pneumonia with multi-organ septic spread. Post-mortem examination revealed Candida spores in intestinal, colonic and rectal tissue. Of note, histopathologic BM analysis revealed signs of burgeoning hematopoietic regeneration (Fig. 1e).
Discussion and conclusions
Recent studies have shed light on the high incidence of prolonged and profound neutropenia after adoptive immunotherapy with CD19-specific CAR T-cells [1–3]. Clinical sequalae include severe infectious complications, which have emerged as the number one cause of long-term non-relapse mortality after CAR T-cell therapy [14]. In a seminal study, Hill and colleagues demonstrate that infectious complications are common with a cumulative incidence of 23% in the first 28 days after CAR T-cell transfusion and 14% between days 29–90. While bacterial infections were most common in the first month, viral infections – especially respiratory viruses – predominated after day 29, likely as a result of an impaired adaptive immune response due to B-cell aplasia [15]. Overall, most infections were mild to moderate and fatal infections were rare. Invasive mold infections were uncommon, ranging from 1 to 7% in CAR T-cell recipients [15–17]. In multivariate analyses, the use of systemic corticosteroids for the management of CRS or ICANS has emerged as a major risk factor of infection [18]. Certain inflammatory signatures – such as the “double peaks of IL-6” pattern observed in our patient – have been shown to confer an especially high risk of life-threatening infection [19].
This case highlights the combination of factors that precipitate a high risk of infectious complications in a CAR T-cell patient. First, the heavily pre-treated patient displayed B-cell aplasia and a diminished hematopoietic reserve (e.g. trilineage cytopenia) prior to lymphodepletion. Second, the patient developed classic complications of CAR T-cell therapy such as CRS and severe and prolonged ICANS, reflecting a pro-inflammatory state that represents an important risk factor for developing infections in CAR T-cell patients [16]. The subsequent application of high-dose corticosteroids impaired both innate and adaptive immunity [20]. Third, pancytopenia was profound, prolonged and not able to be reverted by growth factor support. Fourth, the patient had a history of infectious complications, including a course of fungal pneumonia 6 weeks prior to lymphodepletion, likely flaring up in the setting of the above three factors.
Our patient developed severe septic shock secondary to neutropenic colitis on day 24, highlighting the risk of a watch-and-wait approach to prolonged neutropenia after CAR T-cell therapy. A two-pronged approach to management appears prescient. On the one hand, measures to propagate hematopoietic recovery should be exhausted (causal therapy). This can range from G-CSF stimulation, to a trial of pulse-dose corticosteroids or anti-cytokine therapy (e.g. Anakinra, Tocilizumab), to a stem cell boost as a last resort in lymphoma patients who have undergone prior autologous stem cell transplantation. On the other hand, clinicians should be at high alert for infectious complications and adapt their infection surveillance and anti-infective prophylactic strategies accordingly. For example, therapeutic drug monitoring of posaconazole and meropenem levels may have revealed subtherapeutic dosing of these anti-infective agents in this patient [21]. The role of antifungal prophylaxis in the CAR T-cell patient remains inconclusive. Adequately powered studies addressing the duration of neutropenia after CAR T-cell therapy, and potential clinical determinants of invasive fungal infections, will be critical to gauge the benefit of antifungal prophylaxis in this patient collective.
Candida species are a leading cause of fungus-associated morbidity and mortality in severely immunocompromised patients [21]. On day 41, this patient developed breakthrough C. glabrata Candidemia on micafungin, in the setting of both underlying colonization and neutropenic colitis. A recent report implicated the gastrointestinal tract as major source of echinocandin drug resistance in a murine model of C. glabrata colonization and systemic dissemination [22]. Of note, breakthrough Candida infections on micafungin may occur at the employed dose level (50 mg/day IV), suggesting that this dose may have been inadequate to prevent subsequent Candidemia [23]. Though cases of C. glabrata colitis are extremely rare [24], an opportunistic infection could not be ruled out given that C. glabrata infiltrates were discovered in enteral and colonic mucosal tissue on post-mortem examination. Importantly, the patients’ clinical status deteriorated only after the stem cell boost resulted in signs of hematopoietic recovery. The paradoxical worsening of the pulmonary A. fumigatus infection is consistent with immune reconstitution inflammatory syndrome (IRIS), which has been previously described for HIV/AIDS [25] and for severely neutropenic patients with IPA [26]. In conclusion, this case emphasizes that infectious complications secondary to prolonged cytopenia influence non-relapse mortality after CAR T-cell therapy.
Abbreviations
ALCAbsolute Lymphocyte Count
ANCAbsolute Neutrophil Count
BMBone Marrow
CARChimeric antigen receptor
CBCComplete Blood Count
CRSCytokine release syndrome
CTCAECommon Terminology Criteria for Adverse Events
DLBCLDiffuse large B-cell lymphoma
FFPFresh frozen plasma
FLAIRFluid-attenuated inversion recovery
Flu/CyFludarabine/Cyclophosphamide
G-CSFGranulocyte colony stimulating factor
GIGastrointestinal
GMGalactomannan
HSPCsHematopoietic stem and progenitor cells
ICANSImmune effector cell-associated neurotoxicity syndrome
ICE-scoreImmune Effector Cell-associated Encephalopathy score
ICUIntensive care unit
IPAInvasive pulmonary aspergillosis
LDHLactate Dehydrogenase
LYRICLymphoma response to immunomodulatory therapy criteria
MDRDModification of Diet in Renal Disease
MPOMyeloperoxidase
PASPeriodic acid-Schiff
PBSCPeripheral Blood Stem Cell
VREVancomycin-resistant Enterococcus
WBCWhite Blood Count
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Acknowledgements
Not applicable.
Authors’ contributions
The original manuscript was written by KR. KR and WGK prepared the figures. MR performed the histological examination of the bone marrow. MS reviewed and edited the manuscript. The other authors (VB1, VB2, CS, PK, FS, KD, LvB, JS, OW, MD, MvBB) contributed to patient management and participated in drafting and editing the manuscript. All authors read and approved the final manuscript.
Funding
Not applicable. Open Access funding enabled and organized by Projekt DEAL.
Availability of data and materials
The authors did not use any database, software, or tools for the writing of this manuscript.
Ethics approval and consent to participate
The authors obtained consent from the deceased patient’s next-of-kin to participate.
Consent for publication
Written informed consent was obtained from the patient’s next-of-kin for publication of this Case report and any accompanying images. A copy of the written consent is available for review by the Editor of this journal.
Competing interests
The authors declare that they have no competing interests related with this case report. | Fatal | ReactionOutcome | CC BY | 33509115 | 18,947,434 | 2021-01-28 |
What was the outcome of reaction 'Urinary tract infection'? | Severe Candida glabrata pancolitis and fatal Aspergillus fumigatus pulmonary infection in the setting of bone marrow aplasia after CD19-directed CAR T-cell therapy - a case report.
BACKGROUND
Prolonged myelosuppression following CD19-directed CAR T-cell transfusion represents an important, yet underreported, adverse event. The resulting neutropenia and multifactorial immunosuppression can facilitate severe infectious complications.
METHODS
We describe the clinical course of a 59-year-old patient with relapsed/refractory DLBCL who received Axicabtagene-Ciloleucel (Axi-cel). The patient developed ASTCT grade I CRS and grade IV ICANS, necessitating admission to the neurological ICU and prolonged application of high-dose corticosteroids and other immunosuppressive agents. Importantly, neutropenia was profound (ANC < 100/μl), G-CSF-refractory, and prolonged, lasting more than 50 days. The patient developed severe septic shock 3 weeks after CAR transfusion while receiving anti-fungal prophylaxis with micafungin. His clinical status stabilized with broad anti-infective treatment and intensive supportive measures. An autologous stem cell backup was employed on day 46 to support hematopoietic recovery. Although the counts of the patient eventually started to recover, he developed an invasive pulmonary aspergillosis, which ultimately lead to respiratory failure and death. Postmortem examination revealed signs of Candida glabrata pancolitis.
CONCLUSIONS
This case highlights the increased risk for fatal infectious complications in patients who present with profound and prolonged cytopenia after CAR T-cell therapy. We describe a rare case of C. glabrata pancolitis associated with multifactorial immunosuppression. Although our patient succumbed to a fatal fungal infection, autologous stem cell boost was able to spur hematopoiesis and may represent an important therapeutic strategy for DLBCL patients with CAR T-cell associated bone marrow aplasia who have underwent prior stem cell harvest.
Background
When CD19-directed Chimeric Antigen Receptor (CAR) T-cell therapies were first introduced into the clinical setting, a set of distinctive side effects were observed, including Cytokine Release Syndrome (CRS) and immune effector cell-associated neurotoxicity syndrome (ICANS). As these treatments transition from large clinical trials to real-world implementation, new nuances of the side effect spectrum have emerged. This includes the observation that patients can present not only with grade 3–4 cytopenia (CTCAE v5.0), but also a syndrome of persistent cytopenia after CAR T-cell transfusion [1, 2]. Hematologic toxicity is common with one study demonstrating that neutropenia, thrombocytopenia and anemia occur in 94, 80 and 51% of patients respectively [3]. Risk factors for hematotoxicity include CRS grade, baseline cytopenia, and prior allogeneic stem cell transplantation within the last year [2, 3]. The fact that baseline hematopoietic reserve contributes to cytopenia in CAR T-cell patients may explain the variability in the incidence of hematoxicity in the real-world setting compared to the large registration trials, which set stringent hematologic exclusion criteria [4, 5]. The clinical utility of therapeutic rescue strategies that mitigate the risk of infectious complications secondary to long-term bone marrow (BM) aplasia, such as early autologous stem cell boost or Eltrombopag, remains unknown. Moreover, the relative paucity of reports concerning severe and life-threatening infections in the reported CD19-directed CAR T-cell trials necessitates the presentation of distinctive clinical courses that underline the risks of persistent cytopenia after CAR T-cell therapy in a real-world setting.
Case presentation
The 59-year-old male patient was initially diagnosed with stage IIIA follicular lymphoma in January 2018, which transformed to germinal center B-cell like DLBCL in October of the same year. Refractory to multiple cycles of Rituximab-based immunochemotherapy (Fig. 1a), the patient underwent leukapheresis for CAR T-cell therapy in April 2019. The patient experienced significant lymphoma progression during the manufacturing process of Axicabtagene ciloleucel (Axi-cel), manifesting itself in the form of malignant pleural effusions and progressive lymphadenopathy (Fig. 2a,c,e). In the six-week period between leukapheresis and lymphodepletion, the patient remained severely neutropenic after R-CHOP and developed possible invasive fungal disease (IFD) [6] (Fig. 3e) as well as E. coli septicemia secondary to a urinary tract infection. These infections were treated successfully with liposomal amphotericin B and piperacillin/tazobactam. Prior to lymphodepletion (D-5), the patient presented with an ECOG performance status of 1, intact renal and liver function, while observing residually depressed blood counts (WBC 1270/μl, ANC 700/μl, ALC 390/μl, Hemoglobin 7.2 g/dl, Platelets 20 G/l). BM histopathology showed a hypocellular marrow with no evidence of lymphoma infiltration. Analysis of lymphocyte subpopulations demonstrated severe B-cell aplasia and decreased absolute CD4+ (84/μl) and CD8+ (271/μl) counts. His anti-infective prophylaxis consisted of a combination of acyclovir, sulfamethoxazole/trimethoprim (TMP/SMZ), and posaconazole. The fludarabine/cyclophosphamide lympho-preparative regimen was applied on days − 5 to − 3 according to the provider’s protocol, followed by CAR T-cell transfusion on day 0.
Fig. 1 Overview of CAR T-cell mediated hematotoxicity and infectious complications. a Treatment course prior to CAR T-cell therapy. b Timeline of infectious complications during CAR T-cell treatment course. Positive microbiologic culture results are underlined. Bottom: Overview of utilized anti-infectives with the respective bars displaying the length of treatment. P/T = piperacillin/tazobactam, Ami = amikacin, Mero = meropenem, Vanco = vancomycin, Line = linezolid, Posa = posaconazole (p.o.), Mica = micafungin (i.v.), Amb = liposomal amphotericin B. The patient also received prophylactic acyclovir and sulfamethoxazole/trimethoprim (TMP/SMZ) during treatment. c Complete Blood Count (CBC) timeline. ANC (blue), platelet count (green), Hemoglobin (red). Transfusion events (green: platelet transfusion, red: pRBC transfusion) and G-CSF support (blue bar) are integrated in the curve. d Dynamics of Serum Inflammatory Markers. Infectious complications are superimposed above the graph. e Histopathologic analysis of BM biopsies demonstrating severe BM aplasia 1 month after CAR T-cell transfusion (Day 32, upper panel) and evidence of recovering hematopoiesis following autologous stem cell transfer (Autopsy, lower panel). Immunohistochemical staining for myeloperoxidase (= MPO) highlighting strong activation of myelopoiesis (right panel)
Fig. 2 Radiographic evidence of partial response to Axi-cel after 36 days. Contrast-enhanced CT abdomen (axial view) displaying pleural manifestations before (a) and after (b) CAR T-cell treatment. Involved paraaortic lymph nodes (red arrows) demonstrate an interval decrease in size (c-d, e-f). The inset of panel F depicts splenic hypodensities consistent with necrosis of tumor tissue secondary to immune therapy and a reduction of splenomegaly. G Graphical depiction of response over time. Tumor extent was quantified as the sum of the product of perpendicular diameters according to Lugano criteria over 3 time points and is graphed on the y-axis. H Timeline of LDH levels (U/l). The increase in LDH levels at day 25 correlated with the gastrointestinal toxicity and liver dysfunction
Fig. 3 Multi-organ toxicity secondary to CD19-directed CAR T-cell therapy. a Contrast-enhanced CT abdomen demonstrating a non-inflamed baseline state of GI mucosal tissue prior to CAR T therapy. b Panmural swelling of the sigma (left panel), ascending colon (middle panel), and stomach. c Non-pathologic CT of the brain. d Axial FLAIR-weighted (left), T1-weighted contrast-enhanced (middle), and diffusion-weighted (right) MRI displaying no evidence of cerebral edema, white matter lesions, diffusion restriction, microbleeds, meningeal enhancement or contrast enhancing lesions. e High-resolution CT thorax with bilateral fungal infiltrates observing the typical halo configuration 6 weeks prior to CAR T-cell transfusion. f On day − 3 the right-sided infiltrates have decreased in size. The left lung is collapsed due to malignant pleural effusion. g Lung parenchyma exhibiting an infiltration of non-dimorphic blastoconidial morphology consistent with Candida glabrata. h PAS staining of a lung specimen highlights septated hiphae and acute-angle branching, features consistent of with aspergillus infection
During lymphodepletion the patient developed an upper respiratory infection, presenting with a non-productive cough and a sputum culture positive for Bordetella bronchiseptica, which resolved clinically after antibiotic treatment with piperacillin/tazobactam. On day 7, the patient developed fever with a stable cardiopulmonary function and concomitant IL-6 rise (Fig. 1d), which was classified as CRS grade I according to ASTCT consensus grading [7] in the absence of positive blood cultures and other foci. Due to persistent fever refractory to antipyretic treatment, four total doses of tocilizumab (8 mg/kg) were applied over 36 h. Starting on day 9, the patient deteriorated neurologically with a depressed state of consciousness prompting the diagnosis of grade IV ICANS. The patient was transferred to the neurological ICU, and high-dose corticosteroids (methylprednisolone 1000 mg daily) were initiated. CSF-analysis displayed subtle pleocytosis, but revealed no signs of CNS infection (viral, bacterial and fungal) or meningeal involvement of the DLBCL. CT and MR imaging of the brain exhibited none of the pathological findings reported for ICANS [8] or CNS infection [9](Fig. 3c-d). After 5 days of high-dose methylprednisolone, the patient’s neurological status slowly improved, and corticosteroids could be tapered.
Partial response to Axicabtagene-Ciloleucel after 36 days according to Lugano criteria
While the patient’s initial clinical course was fraught with complications, CT staging performed at day 36 demonstrated a partial response to CAR T-cell therapy according to Lugano and Lyric criteria (Fig. 2a-g). This was particularly evident for the pleural manifestations of the underlying DLBCL, which was accompanied by an interval decrease in pleural effusions and subjective dyspnea (Fig. 2a-b). Multiple nodal sites including paraaortic (Fig. 2c-d) and parailiac lymph nodes (Fig. 2e-f) exhibited significant regression of tumor size (Fig. 2g). Moreover, the patient displayed splenic hypodensities consistent with either tumor tissue necrosis or infection-associated inflammatory changes (inset, Fig. 2f). These CT-morphologic findings were accompanied by a decrease of LDH levels (Fig. 2h).
Prolonged cytopenia lead to the development of severe neutropenic colitis and fatal fungal pneumonia
The patient presented with significant myelotoxicity and sustained transfusion dependency after CAR T-cell administration (Fig. 1c). The overall duration of profound neutropenia – defined as an ANC < 100/μl [10] – was 52 days. Because of the severity of ICANS, the clinicians chose to hold G-CSF during this time period due to concerns for risk of worsening toxicity [11].
While receiving broad anti-infectives (acyclovir, TMP/SMZ, posaconazole, meropenem), the patient developed breakthrough septic shock on day 24. He exhibited fever (39.5 °C), hypotension (70/30 mmHg), tachycardia (160/min), as well as lactic acidosis (lactate: 10.7 mmol/l). The patient was non-conversant, non-oriented, and was not able to localize symptoms. However, he had described epigastric tenderness and subtle changes in stool consistency and frequency on the previous day. As a result, abdominal CT imaging was obtained, which displayed severe pancolitis, as evidenced by pronounced mucosal thickening with edematous changes ranging from the ascending colon to the rectum (Fig. 3a-b). Labs were notable for an acute spike of serum inflammatory parameters (Il-6 > 500.000 pg/ml, CRP 5.7 mg/dl, Procalcitonin 11.2 ng/ml, Fig. 1d). Following ICU transfer, high-dose vasopressor support with norepinephrine was initiated together with volume resuscitation to maintain organ perfusion. Due to progressive loss of consciousness the patient was intubated and mechanically ventilated. To control the proinflammatory state, extracorporeal cytokine absorption (Cytosorb®) was performed, which resulted in a decrease of soluble inflammatory markers in the subsequent days. Arterial blood cultures were positive for vancomycin-resistant enterococci (VRE), and the antibiotic treatment was escalated to include linezolid along with meropenem (Fig. 1b). The ICU team transitioned antifungal prophylaxis from posaconazole to an echinocandine (micafungin 50 mg IV) due to ECG changes and concerns for drug interactions on day 24. Though he remained in critical condition, in the coming weeks his clinical condition stabilized and both the catecholamine rate and volume support could be reduced. To determine the origin of sustained myelosuppression, a bone marrow biopsy was obtained, which depicted a hypocellular marrow and severe aplasia affecting all hematopoietic lineages (Fig. 1e). On days 41 and 49, surveillance blood cultures were positive for Candida glabrata, a commensal fungal organism of human mucosal tissues [12] harboring an intrinsic azole resistance [13]. Susceptibility testing confirmed the azole-resistance of C. glabrata isolates. The antimycotic therapy was escalated from micafungin to liposomal amphotericin B. C. glabrata likely disseminated to the bloodstream secondary to the described gastrointestinal toxicity and was previously discovered on rectal swab (Fig. 1b) and fecal culture (day − 51).
Due to sustained neutropenia, BM aplasia and the availability of a suitable apheresis product, the CAR T-cell Taskforce proceeded with a stem cell boost of previously collected autologous CD34+ cells (3,1 × 106 cells) on day 46. The combination of a sudden rise in serum inflammatory markers and a strongly positive serum galactomannan (GM) assay on day 49 prompted diagnostic bronchoscopy, which revealed a diffuse infiltrate of alveolar and peri-bronchial tissue by Aspergillus fumigatus, consistent with fulminant invasive fungal pneumonia. Over the next week, the patient became increasingly hemodynamically unstable with poor peripheral oxygenation. Repeat bronchoscopy with bronchial lavage was positive for A. fumigatus and C. glabrata. After 50 days of G-CSF refractory aplasia, the autologous stem cells slowly engrafted leading to neutrophil recovery. However, this likely exacerbated the local inflammatory reaction in the lung, contributing to rapid deterioration of his respiratory status. Despite extensive supportive measures, the patient died on day 58 after CAR T-cell transfusion. Cause of death was confirmed by autopsy as invasive fungal pneumonia with multi-organ septic spread. Post-mortem examination revealed Candida spores in intestinal, colonic and rectal tissue. Of note, histopathologic BM analysis revealed signs of burgeoning hematopoietic regeneration (Fig. 1e).
Discussion and conclusions
Recent studies have shed light on the high incidence of prolonged and profound neutropenia after adoptive immunotherapy with CD19-specific CAR T-cells [1–3]. Clinical sequalae include severe infectious complications, which have emerged as the number one cause of long-term non-relapse mortality after CAR T-cell therapy [14]. In a seminal study, Hill and colleagues demonstrate that infectious complications are common with a cumulative incidence of 23% in the first 28 days after CAR T-cell transfusion and 14% between days 29–90. While bacterial infections were most common in the first month, viral infections – especially respiratory viruses – predominated after day 29, likely as a result of an impaired adaptive immune response due to B-cell aplasia [15]. Overall, most infections were mild to moderate and fatal infections were rare. Invasive mold infections were uncommon, ranging from 1 to 7% in CAR T-cell recipients [15–17]. In multivariate analyses, the use of systemic corticosteroids for the management of CRS or ICANS has emerged as a major risk factor of infection [18]. Certain inflammatory signatures – such as the “double peaks of IL-6” pattern observed in our patient – have been shown to confer an especially high risk of life-threatening infection [19].
This case highlights the combination of factors that precipitate a high risk of infectious complications in a CAR T-cell patient. First, the heavily pre-treated patient displayed B-cell aplasia and a diminished hematopoietic reserve (e.g. trilineage cytopenia) prior to lymphodepletion. Second, the patient developed classic complications of CAR T-cell therapy such as CRS and severe and prolonged ICANS, reflecting a pro-inflammatory state that represents an important risk factor for developing infections in CAR T-cell patients [16]. The subsequent application of high-dose corticosteroids impaired both innate and adaptive immunity [20]. Third, pancytopenia was profound, prolonged and not able to be reverted by growth factor support. Fourth, the patient had a history of infectious complications, including a course of fungal pneumonia 6 weeks prior to lymphodepletion, likely flaring up in the setting of the above three factors.
Our patient developed severe septic shock secondary to neutropenic colitis on day 24, highlighting the risk of a watch-and-wait approach to prolonged neutropenia after CAR T-cell therapy. A two-pronged approach to management appears prescient. On the one hand, measures to propagate hematopoietic recovery should be exhausted (causal therapy). This can range from G-CSF stimulation, to a trial of pulse-dose corticosteroids or anti-cytokine therapy (e.g. Anakinra, Tocilizumab), to a stem cell boost as a last resort in lymphoma patients who have undergone prior autologous stem cell transplantation. On the other hand, clinicians should be at high alert for infectious complications and adapt their infection surveillance and anti-infective prophylactic strategies accordingly. For example, therapeutic drug monitoring of posaconazole and meropenem levels may have revealed subtherapeutic dosing of these anti-infective agents in this patient [21]. The role of antifungal prophylaxis in the CAR T-cell patient remains inconclusive. Adequately powered studies addressing the duration of neutropenia after CAR T-cell therapy, and potential clinical determinants of invasive fungal infections, will be critical to gauge the benefit of antifungal prophylaxis in this patient collective.
Candida species are a leading cause of fungus-associated morbidity and mortality in severely immunocompromised patients [21]. On day 41, this patient developed breakthrough C. glabrata Candidemia on micafungin, in the setting of both underlying colonization and neutropenic colitis. A recent report implicated the gastrointestinal tract as major source of echinocandin drug resistance in a murine model of C. glabrata colonization and systemic dissemination [22]. Of note, breakthrough Candida infections on micafungin may occur at the employed dose level (50 mg/day IV), suggesting that this dose may have been inadequate to prevent subsequent Candidemia [23]. Though cases of C. glabrata colitis are extremely rare [24], an opportunistic infection could not be ruled out given that C. glabrata infiltrates were discovered in enteral and colonic mucosal tissue on post-mortem examination. Importantly, the patients’ clinical status deteriorated only after the stem cell boost resulted in signs of hematopoietic recovery. The paradoxical worsening of the pulmonary A. fumigatus infection is consistent with immune reconstitution inflammatory syndrome (IRIS), which has been previously described for HIV/AIDS [25] and for severely neutropenic patients with IPA [26]. In conclusion, this case emphasizes that infectious complications secondary to prolonged cytopenia influence non-relapse mortality after CAR T-cell therapy.
Abbreviations
ALCAbsolute Lymphocyte Count
ANCAbsolute Neutrophil Count
BMBone Marrow
CARChimeric antigen receptor
CBCComplete Blood Count
CRSCytokine release syndrome
CTCAECommon Terminology Criteria for Adverse Events
DLBCLDiffuse large B-cell lymphoma
FFPFresh frozen plasma
FLAIRFluid-attenuated inversion recovery
Flu/CyFludarabine/Cyclophosphamide
G-CSFGranulocyte colony stimulating factor
GIGastrointestinal
GMGalactomannan
HSPCsHematopoietic stem and progenitor cells
ICANSImmune effector cell-associated neurotoxicity syndrome
ICE-scoreImmune Effector Cell-associated Encephalopathy score
ICUIntensive care unit
IPAInvasive pulmonary aspergillosis
LDHLactate Dehydrogenase
LYRICLymphoma response to immunomodulatory therapy criteria
MDRDModification of Diet in Renal Disease
MPOMyeloperoxidase
PASPeriodic acid-Schiff
PBSCPeripheral Blood Stem Cell
VREVancomycin-resistant Enterococcus
WBCWhite Blood Count
Publisher’s Note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
Acknowledgements
Not applicable.
Authors’ contributions
The original manuscript was written by KR. KR and WGK prepared the figures. MR performed the histological examination of the bone marrow. MS reviewed and edited the manuscript. The other authors (VB1, VB2, CS, PK, FS, KD, LvB, JS, OW, MD, MvBB) contributed to patient management and participated in drafting and editing the manuscript. All authors read and approved the final manuscript.
Funding
Not applicable. Open Access funding enabled and organized by Projekt DEAL.
Availability of data and materials
The authors did not use any database, software, or tools for the writing of this manuscript.
Ethics approval and consent to participate
The authors obtained consent from the deceased patient’s next-of-kin to participate.
Consent for publication
Written informed consent was obtained from the patient’s next-of-kin for publication of this Case report and any accompanying images. A copy of the written consent is available for review by the Editor of this journal.
Competing interests
The authors declare that they have no competing interests related with this case report. | Recovered | ReactionOutcome | CC BY | 33509115 | 18,947,434 | 2021-01-28 |
Give an alphabetized list of all active substances of drugs taken by the patient who experienced 'Hepatitis acute'. | Successful treatment with alectinib after crizotinib-induced hepatitis in ALK-rearranged advanced lung cancer patient: a case report.
BACKGROUND
Besides the clinical benefit of crizotinib in ALK-rearranged metastatic non-small cell lung cancer (NSCLC), concerns about its hepatotoxicity have arisen. It is not clear whether this is a drug class side effect or if the use of other selective ALKs inhibitors is safe after this serious adverse event. While evidence from clinical trials is scarce, reports of treatment after crizotinib-induces hepatitis may add to clinical decision.
METHODS
Herein, we report a case of acute hepatitis induced by crizotinib in a 32-years-old female diagnosed with metastatic NSCLC, harboring the ALK-rearrangement. After 60 days of crizotinib therapy, the patient presented with acute hepatitis, diagnosed after investigation of non-specific symptoms, such as nausea and fatigue. Serum aspartate aminotransferase and alanine aminotransferase levels had increased from baseline to 3010 IU/L and 9145 IU/L, respectively. Total bilirubin increased up to 7.91 mg/dL, but she did not develop liver failure. After crizotinib discontinuation, a gradual hepatic function recovery occurred. Unfortunately, during the period without specific oncology treatment, her disease showed an unequivocal progression. Therefore, she started on alectinib with great response, and no liver function alteration recurred.
CONCLUSIONS
This case suggests that alectinib, even belonging to the same drug class, could be used as an alternative agent when crizotinib is the etiology of liver damage, but more robust evidence has awaited.
Background
Non-small-cell lung cancer (NSCLC) accounts for 80% of lung malignancies, the leading cause of cancer deaths worldwide. Unfortunately, the majority is already unresectable or metastatic upon its diagnosis [1] and will require systemic therapy. Adenocarcinoma is the most common NSCLC histologic subtype, and nowadays, its treatment relies on the molecular signature, tailored by specific driver mutations [2].
The anaplastic lymphoma kinase (ALK) fusion gene, found in 3–5% of NSCLC, is a driver mutation for which target therapies are available, such as crizotinib, first-in-class, multitargeted tyrosine kinase inhibitor (TKI) [3]. In patients with locally advanced or metastatic ALK-positive NSCLC, this oral drug showed improved survival compared to conventional chemotherapy [4–6].
Besides its clinical benefit, concerns about crizotinib hepatotoxicity have arisen. In the phase 3 trial PROFILE 1014, which granted the drug approval in Brazil and many other countries for ALK-positive NSCLC patients, 14% of patients in the crizotinib arm developed grade 3 transaminases elevation [5].
Since then, case reports have been published describing crizotinib potential liver injury and its management. However, it is not clear whether this is a drug class side effect or if the use of other selective ALKs inhibitors is safe after this severe toxicity.
Herein, we report a real-world case of acute hepatitis induced by crizotinib in an ALK-rearranged positive NSCLC patient, in whom the treatment shift for a second-generation ALK-inhibitor after the event recovery. A complete metabolic response was achieved, and no serious adverse events occurred.
Case presentation
A 32-years-old female, non-smoker, had 3-months onset symptoms of dyspnea and cough. There were no comorbidities or medicine use. Her computer tomography (CT) scans showed multiple bilateral nodules associated with lymphangitis signs, enlarged bilateral mediastinal lymph nodes, and thoracic vertebral bone lesion. She underwent a right inferior lobe segmentectomy, whose path report showed a lung carcinoma. No brain metastasis was identified by MRI, and the PET-CT has not performed at initial staging.
As the symptoms were getting worse, the treatment based on carboplatin plus paclitaxel initiated, while complimentary histopathologic and molecular investigations have performed. After two cycles, the immunohistochemistry confirmed a pulmonary adenocarcinoma, and the ALK rearrangement (2p23q in more than 15% of the specimen) was detected by fluorescence in situ hybridization test. Moreover, PDL-1 was 40%, EGFR, ROS-1, MET, RET, ERBB2, and BRAF were negative.
Since the ALK-positive stage IV pulmonary adenocarcinoma diagnosis, the treatment has promptly adjusted for crizotinib—the only TKI approved in Brazil for this scenario at that moment—250 mg twice daily, on November 11th, 2018. After almost 60 days of therapy, despite respiratory symptoms improvement, the patient presented some non-specific complaints such as nausea and fatigue. Physical examination with no relevant finding, including jaundice. By December 21st, her laboratory review showed a severe liver dysfunction, shown in graph 1. Due to acute hepatitis, crizotinib therapy has halted. Viral involvement and other etiologies were investigated and excluded. Thenceforth, a gradual liver function recovery has occurred. On February 18th, 2019, blood tests did not show any significant alteration.
Meanwhile, during the period without specific oncology treatment, dyspnea and cough recurred, and the patient developed a headache onset. Central nervous system (CNS)—multiple small lesions along brain parenchyma—and lung progression were detected on February 4th.
Since then, she started on alectinib 600 mg orally twice daily. A few weeks later, she completely recovered from her respiratory symptoms, and no liver function alteration recurred (see Fig. 1).Fig. 1 Serum bilirrubin and liver enzymes curves since lung cancer diagnosis
The patient is still under full dose alectinib therapy with excellent tolerability and no adverse effects. PET-CT performed on May 8th did not show any metabolic activity as well as the brain MRI did not show any evidence of CNS involvement.
Discussion and conclusions
This report describes a successful case of treatment with alectinib after crizotinib-induced hepatitis. This serious adverse event may be ascribed to crizotinib due to the temporal relationship between drug beginning and the transaminases elevation and due to its resolution after the medication interruption.
So far, the mechanism of crizotinib liver toxicity is not clear, and specific risk factors or clinicopathologic predictors for crizotinib-induced liver injury have not yet been identified. The reported general risk factors of drug-induced hepatotoxicity include older age, female gender, HIV infection, HBV or HCV infection, pregnancy, excessive alcohol intake, smoking, and genetic variability [7, 8]. According to its prescribing information, the hepatotoxicity generally occurs within the first 2 months of the treatment, which was compatible with the case reported. Considerations about the pharmacodynamic properties are important regarding drug side effects. The liver metabolizes crizotinib, and CYP3A plays a major role. Therefore, we should avoid concomitant use of CYP3A inducers and inhibitors, which may alter crizotinib plasma concentrations [9]. However, there was no concomitant drug used by our patient.
Alectinib, a second-generation TKI targeting ALK, is also associated with elevations of AST and ALT, as showed by clinical trials. Among the 405 patients enrolled in intervention arms in NP28761, NP28673, and ALEX studies, AST and ALT elevations greater than five times the upper limit of normal (ULN) occurred in 4.6% and 5.3% respectively, bilirubin levels more than three times the ULN occurred in 3.7%. In the majority of patients, these events occurred in the first 3 months of treatment. Ten patients discontinued alectinib due to Grades 3–4 AST/ALT (n = 6) and bilirubin (n = 4) elevations. Thus, monitoring liver function tests, including ALT, AST, and total bilirubin every two weeks during the first 3 months of treatment, then once a month, or whenever clinically indicated, is strongly advisable [10].
This case report harbors some limitations. We did not perform a liver biopsy, and the association between the crizotinib with the liver damage was established only based on clinic and temporal criteria, which reflects real-world practice. Moreover, there is no specific recommendation regarding the use of alectinib after recovering from crizotinib-induced hepatitis. However, the patient had disease progression after crizotinib interruption, and the alectinib was the best option in the second-line setting at that time, based on phase II studies. At that time, other TKI targeted to ALK-rearrangement was not available in Brazil [11].
It is important to highlight the contribution of the present report: although the described occurrence of liver toxicity with both TKIs, hepatitis induced by one drug does not exclude the possibility of treatment with another specific ALK-TKIs.
While evidence from clinical trials is scarce, experiences like that, in a real-world scenario, may add to clinical decision. Once this class of drugs changed the natural history of the disease, its definitive discontinuation could impact the patient´s overall survival.
In conclusion, this case suggests that alectinib could be an alternative agent when crizotinib is the etiology of hepatitis. Therefore, patients might still derive benefit from target therapy.
Abbreviations
NSCLCNon-small cell lung cancer
ALKAnaplastic lymphoma kinase
TKITyrosine kinase inhibitor
CTComputer tomography
CNSCentral nervous system
ULNUpper limit of normal
Publisher's Note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
Acknowledgements
Not applicable.
Authors’ contributions
HA and LR were responsible for case conduction, supported the data collection, and revised the manuscript and language correction. FP collected the data and edited the manuscript. FD and PD collected and analysed data; wrote the manuscript; revised and edited the manuscript. All authors read and approved the final manuscript.
Funding
Not applicable.
Availability of data and materials
The data that support this case report are available from the corresponding author on reasonable request, since respecting the Ethics Committee to protect patient confidentiality.
Ethics approval and consent to participate
Written informed consent was obtained from the patient. Ethics approval is not applicable to case reports.
Consent for publication
Written informed consent was obtained from the patient for publication of this case report and any accompanying images. A copy of the written consent is available for review by the Editor of this journal.
Competing interests
Dr. Duarte reports personal fees and non-financial support from F. Hoffmann–La Roche AG, outside the submitted work;.Dr. Rodrigues reports personal fees from F. Hoffmann–La Roche AG, AstraZeneca PLC, Johnson and Johnson, DePuy Synthes and Medtronic, outside the submitted work; Dr.Paes reports non-financial support from Pfizer, Inc., outside the submitted work; Dr. Diniz has nothing to disclose; Dr. Almada reports personal fees and non-financial support from F. Hoffmann-La Roche AG and Astrazeneca, outside the submitted work. | CRIZOTINIB | DrugsGivenReaction | CC BY | 33509141 | 18,886,043 | 2021-01-28 |
What was the outcome of reaction 'Hepatitis acute'? | Successful treatment with alectinib after crizotinib-induced hepatitis in ALK-rearranged advanced lung cancer patient: a case report.
BACKGROUND
Besides the clinical benefit of crizotinib in ALK-rearranged metastatic non-small cell lung cancer (NSCLC), concerns about its hepatotoxicity have arisen. It is not clear whether this is a drug class side effect or if the use of other selective ALKs inhibitors is safe after this serious adverse event. While evidence from clinical trials is scarce, reports of treatment after crizotinib-induces hepatitis may add to clinical decision.
METHODS
Herein, we report a case of acute hepatitis induced by crizotinib in a 32-years-old female diagnosed with metastatic NSCLC, harboring the ALK-rearrangement. After 60 days of crizotinib therapy, the patient presented with acute hepatitis, diagnosed after investigation of non-specific symptoms, such as nausea and fatigue. Serum aspartate aminotransferase and alanine aminotransferase levels had increased from baseline to 3010 IU/L and 9145 IU/L, respectively. Total bilirubin increased up to 7.91 mg/dL, but she did not develop liver failure. After crizotinib discontinuation, a gradual hepatic function recovery occurred. Unfortunately, during the period without specific oncology treatment, her disease showed an unequivocal progression. Therefore, she started on alectinib with great response, and no liver function alteration recurred.
CONCLUSIONS
This case suggests that alectinib, even belonging to the same drug class, could be used as an alternative agent when crizotinib is the etiology of liver damage, but more robust evidence has awaited.
Background
Non-small-cell lung cancer (NSCLC) accounts for 80% of lung malignancies, the leading cause of cancer deaths worldwide. Unfortunately, the majority is already unresectable or metastatic upon its diagnosis [1] and will require systemic therapy. Adenocarcinoma is the most common NSCLC histologic subtype, and nowadays, its treatment relies on the molecular signature, tailored by specific driver mutations [2].
The anaplastic lymphoma kinase (ALK) fusion gene, found in 3–5% of NSCLC, is a driver mutation for which target therapies are available, such as crizotinib, first-in-class, multitargeted tyrosine kinase inhibitor (TKI) [3]. In patients with locally advanced or metastatic ALK-positive NSCLC, this oral drug showed improved survival compared to conventional chemotherapy [4–6].
Besides its clinical benefit, concerns about crizotinib hepatotoxicity have arisen. In the phase 3 trial PROFILE 1014, which granted the drug approval in Brazil and many other countries for ALK-positive NSCLC patients, 14% of patients in the crizotinib arm developed grade 3 transaminases elevation [5].
Since then, case reports have been published describing crizotinib potential liver injury and its management. However, it is not clear whether this is a drug class side effect or if the use of other selective ALKs inhibitors is safe after this severe toxicity.
Herein, we report a real-world case of acute hepatitis induced by crizotinib in an ALK-rearranged positive NSCLC patient, in whom the treatment shift for a second-generation ALK-inhibitor after the event recovery. A complete metabolic response was achieved, and no serious adverse events occurred.
Case presentation
A 32-years-old female, non-smoker, had 3-months onset symptoms of dyspnea and cough. There were no comorbidities or medicine use. Her computer tomography (CT) scans showed multiple bilateral nodules associated with lymphangitis signs, enlarged bilateral mediastinal lymph nodes, and thoracic vertebral bone lesion. She underwent a right inferior lobe segmentectomy, whose path report showed a lung carcinoma. No brain metastasis was identified by MRI, and the PET-CT has not performed at initial staging.
As the symptoms were getting worse, the treatment based on carboplatin plus paclitaxel initiated, while complimentary histopathologic and molecular investigations have performed. After two cycles, the immunohistochemistry confirmed a pulmonary adenocarcinoma, and the ALK rearrangement (2p23q in more than 15% of the specimen) was detected by fluorescence in situ hybridization test. Moreover, PDL-1 was 40%, EGFR, ROS-1, MET, RET, ERBB2, and BRAF were negative.
Since the ALK-positive stage IV pulmonary adenocarcinoma diagnosis, the treatment has promptly adjusted for crizotinib—the only TKI approved in Brazil for this scenario at that moment—250 mg twice daily, on November 11th, 2018. After almost 60 days of therapy, despite respiratory symptoms improvement, the patient presented some non-specific complaints such as nausea and fatigue. Physical examination with no relevant finding, including jaundice. By December 21st, her laboratory review showed a severe liver dysfunction, shown in graph 1. Due to acute hepatitis, crizotinib therapy has halted. Viral involvement and other etiologies were investigated and excluded. Thenceforth, a gradual liver function recovery has occurred. On February 18th, 2019, blood tests did not show any significant alteration.
Meanwhile, during the period without specific oncology treatment, dyspnea and cough recurred, and the patient developed a headache onset. Central nervous system (CNS)—multiple small lesions along brain parenchyma—and lung progression were detected on February 4th.
Since then, she started on alectinib 600 mg orally twice daily. A few weeks later, she completely recovered from her respiratory symptoms, and no liver function alteration recurred (see Fig. 1).Fig. 1 Serum bilirrubin and liver enzymes curves since lung cancer diagnosis
The patient is still under full dose alectinib therapy with excellent tolerability and no adverse effects. PET-CT performed on May 8th did not show any metabolic activity as well as the brain MRI did not show any evidence of CNS involvement.
Discussion and conclusions
This report describes a successful case of treatment with alectinib after crizotinib-induced hepatitis. This serious adverse event may be ascribed to crizotinib due to the temporal relationship between drug beginning and the transaminases elevation and due to its resolution after the medication interruption.
So far, the mechanism of crizotinib liver toxicity is not clear, and specific risk factors or clinicopathologic predictors for crizotinib-induced liver injury have not yet been identified. The reported general risk factors of drug-induced hepatotoxicity include older age, female gender, HIV infection, HBV or HCV infection, pregnancy, excessive alcohol intake, smoking, and genetic variability [7, 8]. According to its prescribing information, the hepatotoxicity generally occurs within the first 2 months of the treatment, which was compatible with the case reported. Considerations about the pharmacodynamic properties are important regarding drug side effects. The liver metabolizes crizotinib, and CYP3A plays a major role. Therefore, we should avoid concomitant use of CYP3A inducers and inhibitors, which may alter crizotinib plasma concentrations [9]. However, there was no concomitant drug used by our patient.
Alectinib, a second-generation TKI targeting ALK, is also associated with elevations of AST and ALT, as showed by clinical trials. Among the 405 patients enrolled in intervention arms in NP28761, NP28673, and ALEX studies, AST and ALT elevations greater than five times the upper limit of normal (ULN) occurred in 4.6% and 5.3% respectively, bilirubin levels more than three times the ULN occurred in 3.7%. In the majority of patients, these events occurred in the first 3 months of treatment. Ten patients discontinued alectinib due to Grades 3–4 AST/ALT (n = 6) and bilirubin (n = 4) elevations. Thus, monitoring liver function tests, including ALT, AST, and total bilirubin every two weeks during the first 3 months of treatment, then once a month, or whenever clinically indicated, is strongly advisable [10].
This case report harbors some limitations. We did not perform a liver biopsy, and the association between the crizotinib with the liver damage was established only based on clinic and temporal criteria, which reflects real-world practice. Moreover, there is no specific recommendation regarding the use of alectinib after recovering from crizotinib-induced hepatitis. However, the patient had disease progression after crizotinib interruption, and the alectinib was the best option in the second-line setting at that time, based on phase II studies. At that time, other TKI targeted to ALK-rearrangement was not available in Brazil [11].
It is important to highlight the contribution of the present report: although the described occurrence of liver toxicity with both TKIs, hepatitis induced by one drug does not exclude the possibility of treatment with another specific ALK-TKIs.
While evidence from clinical trials is scarce, experiences like that, in a real-world scenario, may add to clinical decision. Once this class of drugs changed the natural history of the disease, its definitive discontinuation could impact the patient´s overall survival.
In conclusion, this case suggests that alectinib could be an alternative agent when crizotinib is the etiology of hepatitis. Therefore, patients might still derive benefit from target therapy.
Abbreviations
NSCLCNon-small cell lung cancer
ALKAnaplastic lymphoma kinase
TKITyrosine kinase inhibitor
CTComputer tomography
CNSCentral nervous system
ULNUpper limit of normal
Publisher's Note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
Acknowledgements
Not applicable.
Authors’ contributions
HA and LR were responsible for case conduction, supported the data collection, and revised the manuscript and language correction. FP collected the data and edited the manuscript. FD and PD collected and analysed data; wrote the manuscript; revised and edited the manuscript. All authors read and approved the final manuscript.
Funding
Not applicable.
Availability of data and materials
The data that support this case report are available from the corresponding author on reasonable request, since respecting the Ethics Committee to protect patient confidentiality.
Ethics approval and consent to participate
Written informed consent was obtained from the patient. Ethics approval is not applicable to case reports.
Consent for publication
Written informed consent was obtained from the patient for publication of this case report and any accompanying images. A copy of the written consent is available for review by the Editor of this journal.
Competing interests
Dr. Duarte reports personal fees and non-financial support from F. Hoffmann–La Roche AG, outside the submitted work;.Dr. Rodrigues reports personal fees from F. Hoffmann–La Roche AG, AstraZeneca PLC, Johnson and Johnson, DePuy Synthes and Medtronic, outside the submitted work; Dr.Paes reports non-financial support from Pfizer, Inc., outside the submitted work; Dr. Diniz has nothing to disclose; Dr. Almada reports personal fees and non-financial support from F. Hoffmann-La Roche AG and Astrazeneca, outside the submitted work. | Recovered | ReactionOutcome | CC BY | 33509141 | 18,886,043 | 2021-01-28 |
Give an alphabetized list of all active substances of drugs taken by the patient who experienced 'Acute respiratory failure'. | Clinically amyopathic dermatomyositis presenting with isolated facial edema complicated by acute respiratory failure: a case report.
BACKGROUND
In clinically amyopathic dermatomyositis, the hallmark cutaneous manifestations are the key to diagnosis. We report a case of clinically amyopathic dermatomyositis which presented with facial edema as the sole cutaneous manifestation and was later complicated by acute respiratory failure leading to death.
METHODS
A 58-year-old woman presented with edema of the face that had developed approximately one year ago. There was no weakness in the extremities, and the serum creatine kinase level was within normal range. On MRI, there was diffuse edematous change in the bilateral masticator and extra-ocular muscles, accompanied by subcutaneous fat infiltration in the face. A shared decision was made to defer muscle biopsy in the facial muscles. The facial swelling almost resolved with medium-dose glucocorticoid therapy but relapsed in days at glucocorticoid doses lower than 15 mg/day. Combination therapy with either azathioprine, mycophenolate, or methotrexate was not successful in maintaining clinical remission, and the swelling became more severe after relapses. A US-guided core-needle biopsy was subsequently performed in the right masseter muscle. On pathologic examination, there was a patchy CD4 + T cell-dominant lymphoplasmacytic infiltration in the stroma, necrosis of the myofibrils and prominent perifascicular atrophy. Based on those findings, a diagnosis of clinically amyopathic dermatomyositis was made. Therapy with gamma-globulin was not effective in maintaining remission. In the sixth week after starting rituximab, she presented to emergency room with altered mental state from acute respiratory failure. Despite treatment with antibiotics, glucocorticoid pulse, cyclosporin, and polymyxin B-immobilized fiber column direct hemoperfusion, she died three weeks later from persistent hypoxemic respiratory failure.
CONCLUSIONS
This case showed the full spectrum and severity of internal organ involvement of dermatomyositis, although the patient presented exclusively with subcutaneous edema limited to the head. The prognosis may be more closely associated with a specific auto-antibody profile than the benign-looking initial clinical manifestation. Close follow-up of lung involvement with prophylactic treatment for Pneumocystis pneumonia and prompt implementation of emerging therapeutic regimens may improve the outcome.
Background
Even before the classification of dermatomyositis (DM) was defined by Bohan and Peter in 1975, it was well known that there was a subgroup of patients who did not have muscle disease, regarded as amyopathic dermatomyositis (ADM)[1]. Studies have shown that there is evidence of subclinical muscle disease in MRI imaging and muscle biopsy in ADM leading to the concept of clinically amyopathic dermatomyositis (CADM), which is defined as absence of clinical muscle disease on physical examination and muscle enzyme analysis for at least six months[2]. In CADM, which represents about 11–20 % of dermatomyositis (DM)[3, 4], the hallmark cutaneous manifestations such as Heliotrope rash, Gottron’s papules, and Gottron’s sign are the key to diagnosis.
There has been a report that suggested that subcutaneous edema is a cutaneous manifestation of DM because it can be the only skin lesion at presentation[5]. In the case series, edematous DM comprised 6 % (5/86) of a DM cohort. In the muscle biopsies of the five cases of edematous DM, there were frequent microinfarctions, which were considered to be induced by vasculitis producing micro-ischemia. In the reported five cases and review of 19 reported cases, there were six cases (3/5 and 3/19, respectively) in which subcutaneous edema was the sole cutaneous manifestation, but all had clinical muscle disease, suggesting that CADM presenting exclusively with subcutaneous edema is very rare. In this study, we report a case of CADM which presented with facial edema as the sole cutaneous manifestation and was later complicated by acute respiratory failure leading to mortality.
Case presentation
A 58-year-old woman presented with edema of the face that had developed approximately one year prior. It was not painful nor pruritic, but she felt it was more prominent on the left side. Courses of antibiotic therapy for a presumed diagnosis of cellulitis had not been effective, but glucocorticoids greatly improved the swelling, which relapsed rapidly with tapering. One week prior, as another course of glucocorticoids prescribed for a diagnosis of angioedema was tapered out, her facial edema relapsed, accompanied by tiny, pruritic vesicular lesions on the chin. Although she was evaluated in neurology and dental clinics, no specific diagnosis was made. She reported ‘dryness’ and ‘itchiness’ of the eyes, but not in the oral cavity.
On evaluation, there was bilateral swelling of the malar and temporal area of the face, involving the periorbital area and eyelid in the left side. On the chin, there was eczematoid vesicular eruption (Fig. 1a). There was no abnormal finding on the examination of the chest and abdomen. There was no edema or rash in the trunk or extremities. Neck flexion was preserved, and the power of the extremities’ motor function was evaluated as five on a scale of zero to five. On ophthalmologic examination, there was swelling of the left upper eyelid, and the anterior chamber was clear and deep in both eyes. Five-minute Schirmer test result was 6 mm in the right eye and 8 mm in the left eye (reference value < 5 mm for dry eye disease, but known to have low sensitivity in mild or moderate cases)[6]. Ocular staining score was 1 and 2 in the right and left eye, respectively (reference value ≥ 5 for classification of primary Sjögren’s syndrome)[7].
Fig. 1 Isolated facial edema and subclinical facial muscle involvement. At initial presentation there was bilateral swelling of the face and of the left eyelid, accompanied by eczematoid eruption on the chin (a). After approximately two weeks of medium-dose glucocorticoid therapy the edema and the lesions were completely resolved (b). However, combination therapy with either azathioprine, mycophenolate, or methotrexate was not successful in maintaining remission at a prednisolone dose lower than 15 mg per day. At the last relapse, there was marked aggravation of facial and eyelid edema (c). Gadolinium-enhanced MRI scan of the head shows diffuse edematous change with enhancement of bilateral masticator muscles (d, masseter muscle [yellow arrow] and lateral pterygoid muscle [black arrow]). There was also swelling of bilateral extra-ocular muscles and edematous change with fat infiltration in the subcutaneous tissues of the anterior scalp, periorbital area, buccal space, and anterior cervical fascia (not shown)
On the initial laboratory evaluation, there were no abnormalities, and the serum creatine phosphokinase (CPK) level was within normal range (Table 1). On serologic evaluation, antinuclear antibody was positive up to 1:160 in titer in homogeneous pattern, but anti-dsDNA Ab and anti-histone Ab was negative. Anti-SSA (> 240 U/mL) and anti-SSB (18 U/mL) antibodies were positive (fluorescent enzyme immunoassay, reference value < 7 U/mL for both); anti-RNP and anti-Smith Ab, negative. Anti-Jo1 antibody and anti-SRP antibody were negative. Anti-neutrophil cytoplasmic antibody was negative and IgG4 level was within normal range: 102 mg/dL (reference 30 ~ 201 mg/dL).
Table 1 Laboratory data
Variable Reference range At initial presentation At the second admission
WBC 4.0 ~ 10.0 × 109/L 5.2 2.84
RBC 4.2 ~ 5.4 × 1012/L 4.23 4.38
Hgb 12.0 ~ 16.0 g/dL 12.4 13.7
Platelet 140 ~ 440 × 109/L 230 166
Differential Count
Neutrophil 40 ~ 80 % 57.8 66.8
Lymphocyte 15 ~ 50 % 30.2 20.8
Monocyte 2 ~ 11 % 7.9 9.2
Eosinophil 0 ~ 7 % 3.5 2.8
Basophil 0 ~ 1 % 0.6 0.4
ESR ~ 120 mm 14 21
Total Protein 6.0 ~ 8.0 g/dl 7.4 7.1
Albumin 3.5 ~ 5.2 g/dl 4.3 4.1
Total Bilirubin ~ 1.2 mg/dl 0.64 1.01
AST 7 ~ 38 U/L 36 50
ALT 4 ~ 43 U/L 32 69
ALP 36 ~ 104 U/L 79 58
Glucose 70 ~ 110 mg/dl 84 109
Total Cholesterol ~ 200 mg/dl 171 204
BUN 6.0 ~ 20.0 mg/dl 16 18.6
Creatinine 0.6 ~ 1.2 mg/dl 0.79 0.82
Direct Bilirubin ~ 0.3 mg/dl 0.19 0.24
LDH ~ 250 IU/L 269 424
CPK 50 ~ 200 U/L 182 317
Uric acid 3.0 ~ 5.5 mg/dl 3.5 3.4
CRP ~ 0.30 mg/dL 0.05 0.68
WBC white blood cell, RBC red blood cell, ESR erythrocyte sedimentation rate, AST aspartate aminotransferase, ALT alanine aminotransferase, ALP alkaline phosphatase, BUN blood urea nitrogen, LDH lactase dehydrogenase, CPK creatine phosphokinase, CRP C-reactive protein
On MRI, there was a diffuse edematous change in the bilateral masticator and extra-ocular muscles, accompanied by subcutaneous fat infiltration in the buccal and periorbital spaces. There was inhomogeneous enhancement of bilateral parotid glands. On PET-CT scan there was diffuse F-18-FDG uptake in the periorbital, frontalis, temporalis, and masseter muscles and the buccal and submandibular spaces without any increased uptake in the extremities or internal organs.
The Head and Neck Surgery and Radiology departments opined that a biopsy of the muscles would entail risk of complications such as bleeding and injury to the muscles. After a discussion with the patient regarding undergoing a muscle biopsy, a presumptive clinical diagnosis of an overlap syndrome of Sjogren’s syndrome with myositis was made and treatment with a medium-dose glucocorticoid (prednisolone 30 mg/day) begun; based on reports of orbital involvement, a good response to therapy, and benign prognosis in myositis associated with Sjogren’s syndrome[8–10]. On 16th day of treatment, the facial swelling was assessed as having completely resolved (Fig. 1b); however, the facial edema relapsed during subsequent days when glucocorticoid doses were lowered to less than 15 mg/day. Combination therapy with azathioprine, mycophenolate, or methotrexate for eight months was not effective in maintaining remission at acceptable doses of glucocorticoid, and the swelling aggravated considerably with the final relapse.
The patient finally agreed to further evaluation and was admitted to the hospital. On examination, there was aggravation of the facial edema (Fig. 1c). There was swelling of the right ankle, without tenderness. Neck flexion was preserved and motor power of extremities was assessed as five on a scale of zero to five. On laboratory evaluation, there was mild elevation of liver transaminases and CPK (Table 1). Serum aldolase was 7.9 U/L (reference < 7.6 U/L). On MRI of the head, there was aggravation of the inflammation (Fig. 1d). On ultrasonography of the right ankle, there was subcutaneous edema without evidence of synovitis. A series of evaluations to screen for malignancy including tumor makers (CA19-9, CEA, and CA125), esophagogastroduodenoscopy, colonoscopy, and mammography did not reveal abnormal findings.
A US-guided core-needle biopsy with an 18-gauge needle was performed in the right masseter muscle. Two pieces of tiny muscle tissue, measuring up to 0.5 × 0.1 cm, were obtained. On pathologic examination, there was moderate size variation of the myofibers, and endomysial and perimysial fibrosis. There was patchy CD4 + T cell-dominant lymphoplasmacytic infiltration in the stroma and atrophy of the myofibers, mainly at the periphery of the fascicles, being consistent with perifascicular atrophy. Necrosis of the myofibers was not prominent (Fig. 2). Based on these findings, a diagnosis of clinically amyopathic dermatomyositis was made.
Fig. 2 Biopsy specimens from the right masseter muscle. Hematoxylin and eosin staining shows moderate size variation of the myofibers and endomysial and perimysial fibrosis (white arrow). There is atrophy of the myofibers, mainly at the periphery of the fascicles (black arrow), which is consistent with perifascicular atrophy (a). Patchy lymphoplasmacytic infiltration (white arrow) is noted in the stroma (b), which consists of predominantly more CD4-positive cells (c) than CD8-positive cells (d) in immunohistochemical staining. All figures are at 200-fold magnification
Therapy with gamma-globulin (IVIG, 2.1 g/kg per month) in combination with prednisolone 30 mg/day was initiated, and after the first cycle the facial edema had resolved completely. However, when the dose of prednisolone was decreased to 15 mg/day, she made an earlier visit to the clinic with a relapse of the facial edema within six days. By the fourth cycle of IVIG, sustained remission could not be achieved. A course of rituximab (1.0 g twice, a week apart) in combination with methylprednisolone 40 mg/day was started. In the sixth week of rituximab therapy, when glucocorticoid dose was decreased to methylprednisolone 32 mg/day, she presented to the emergency room with altered mentality that began one day prior. On presentation, there was a fever of 38.7 °C, and the patient began mechanical ventilation immediately for hypoxemic respiratory failure. On chest X-ray, there was diffuse consolidation in both lung fields (Fig. 3b). On high-resolution CT, there was diffuse consolidation in the dependent portion of the lungs and diffuse ground glass opacity with relative sparing of the base of the lungs (Fig. 3c, d). The next day, the patient underwent bronchoscopy with bronchoalveolar lavage. The total cell count was 12 × 106 cells in 9 mL of fluid. Differential data of each cell type was as follows: macrophage 8 %, neutrophil 83 %, and lymphocyte 9 %. There was no bacteria isolated from the respiratory specimen, and a polymerase chain reaction (PCR) test for respiratory viruses including adenovirus, influenza virus, parainfluenza virus, and respiratory syncytial virus was negative. Pneumocystis jirovecii PCR and Gomori methenamine silver (GMS) staining were positive, and the patient began treatment with trimethoprim-sulfamethoxazole and glucocorticoids; but her hypoxemic respiratory failure progressed, and veno-venous extracorporeal (ECMO) membrane oxygenation was begun three days later. Given the lack of response to antibiotics therapy, glucocorticoid pulse and IV cyclosporine was started in consideration of rapidly progressive interstitial lung disease (RP-ILD). Over the next three weeks, despite the addition of polymyxin B-immobilized fiber column direct hemoperfusion (PMX-DHP)[11], there was no improvement in her hypoxemic respiratory failure, and according to the family’s will, the ECMO was weaned. On that day, she expired from respiratory failure.
Fig. 3 Chest radiographic images before and at the presentation of acute respiratory failure. Chest postero-anterior radiography taken about one month after initiating rituximab therapy shows no clear haziness or infiltration in both lung fields (a). At the presentation of acute respiratory failure with altered mentality (in the sixth week after starting rituximab) there was diffuse bilateral infiltration in both lung fields with relative sparing of both lower lung fields (b). Axial high-resolution computed tomography images show diffuse ground glass opacity in both upper lungs with consolidation in dependent areas (c); The lung base is relatively spared (d)
Discussion and Conclusions
This case, which posed significant diagnostic and therapeutic challenges, leaves important lessons for practice and research. First, isolated localized edema may be the initial manifestation of CADM. Such a case is considered very rare; we could find only one case reported in sufficient detail for us to verify the absence of muscle disease and other cutaneous manifestations, the prognosis of which was not known[12]. Second, although the patient presented initially with mild glucocorticoid-responsive facial edema, her course showed increasing extent of subcutaneous edema, decreasing response to immunomodulating therapy, and acute and severe involvement of the lungs leading to death. This suggests the prognosis cannot be predicted by the initially mild clinical manifestation alone.
Severe respiratory complications in idiopathic inflammatory myopathies such as DM pose considerable challenges to treatment, and the prognosis is poor[13, 14]. Differential diagnoses include cardiac complications, respiratory muscle weakness, drug hypersensitivity, RP-ILD, and severe and opportunistic infections[15, 16]. In many cases, it is difficult to arrive at a specific diagnosis, and there is a therapeutic dilemma of treating a severe autoimmune inflammation and a difficult-to-treat infection at the same time. Also in this case, there are a couple of explanations for the acute respiratory disease. First, the possibility of Pneumocystis pneumonia (PCP) should be considered. Prolonged glucocorticoid therapy is one of the risk factors for PCP in patients undergoing immunomodulating therapy for systemic autoimmune rheumatic diseases, and the patient was not receiving prophylaxis for it because of thrombocytopenia (< 50,000/mm3). Radiographic findings of acutely developed consolidation and ground glass opacity with relative sparing of the lung base is suggestive of PCP, and PCR and GMS staining were positive. In addition, even with appropriate treatment, mortality in fulminant PCP in non-HIV immunocompromised patients is high; in a recent study, the mortality rate in idiopathic inflammatory myopathy (including CADM) patients admitted to ICUs was 79.4 %, and PCP comprised approximately 20 % of the admissions[13]. Second, we believe the possibility of RP-ILD should be considered. From the early 2000s, associations between CADM and RP-ILD with poor prognosis were reported in Northeast Asia, including Korea, with mortality reaching approximately 50 %[17–19]. Later studies identified an association between anti-melanoma differentiation-associated protein 5 (MDA5) antibody and RP-ILD[20] [21], both of which are more common in CADM than in DM[22], and in Asians compared with Caucasians[21]. Recent studies report initial combination immunosuppressive therapies improved survival in RP-ILD in CADM[23], and that in the case of refractories a rescue therapy with tofacitinib may improve the outcome[24, 25]. Although we could not evaluate the presence of anti-MDA5 Ab in this case, which is a limitation of this study, rapidly progressive ILD was a possibility in the differential diagnosis of acute respiratory failure which did not respond to antibiotic therapy. Third, rituximab-induced lung disease could be considered. The patient developed acute respiratory symptoms five weeks and one day after the last rituximab infusion. This was in the period when late-onset respiratory illness may develop after rituximab infusion. However, late-onset rituximab-induced respiratory illness is less frequent than delayed-onset illness, shows a chronic course over weeks or months, and responds well to glucocorticoid therapy[26].
In conclusion, this case showed that CADM can initially manifest as a localized subcutaneous edema as the sole cutaneous manifestation but follow a progressive, refractory, and fatal course with major organ involvement, especially involving the lungs. A specific auto-antibody pattern may better predict the prognosis. Identification of the specific antibody profile and prompt initiation of therapy with proven efficacy may improve the outcome.
Authors’ contributions.
DHL analyzed clinical data and prepared the manuscript. YMK performed pathologic examination of the muscle biopsy samples and wrote the pathologic results. JHR performed the radiologic examination and muscle biopsy and contributed to writing. JHL, CSP, and SHK participated in critical care of the patient and contributed to writing. SL planned the study and performed analysis of data and literature. All authors read and approved the final manuscript.
Publisher’s Note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
Acknowledgements
Not applicable.
Authors' contributions
DHL analyzed clinical data and prepared the manuscript. YMK performed pathologic examination of the muscle biopsy samples and wrote the pathologic results. JHR performed the radiologic examination and muscle biopsy and contributed to writing. JHL, CSP, and SHK participated in critical care of the patient and contributed to writing. SL planned the study and performed analysis of data and literature. All authors read and approved the final manuscript.
Funding
Not applicable.
Availability of data and materials
Not applicable.
Ethics approval and consent to participate
This study was approved by the institutional review board of Haeundae Paik hospital (IRB file number: HPIRB 2019-08-016-001).
Consent for publication
Written informed consent was obtained from the patient, including the use of photographs of the face.
Competing interests
The authors declare that they have no competing interests. | HUMAN IMMUNOGLOBULIN G, METHYLPREDNISOLONE, PREDNISONE, RITUXIMAB | DrugsGivenReaction | CC BY | 33509162 | 18,862,926 | 2021-01-28 |
Give an alphabetized list of all active substances of drugs taken by the patient who experienced 'Disease progression'. | Clinically amyopathic dermatomyositis presenting with isolated facial edema complicated by acute respiratory failure: a case report.
BACKGROUND
In clinically amyopathic dermatomyositis, the hallmark cutaneous manifestations are the key to diagnosis. We report a case of clinically amyopathic dermatomyositis which presented with facial edema as the sole cutaneous manifestation and was later complicated by acute respiratory failure leading to death.
METHODS
A 58-year-old woman presented with edema of the face that had developed approximately one year ago. There was no weakness in the extremities, and the serum creatine kinase level was within normal range. On MRI, there was diffuse edematous change in the bilateral masticator and extra-ocular muscles, accompanied by subcutaneous fat infiltration in the face. A shared decision was made to defer muscle biopsy in the facial muscles. The facial swelling almost resolved with medium-dose glucocorticoid therapy but relapsed in days at glucocorticoid doses lower than 15 mg/day. Combination therapy with either azathioprine, mycophenolate, or methotrexate was not successful in maintaining clinical remission, and the swelling became more severe after relapses. A US-guided core-needle biopsy was subsequently performed in the right masseter muscle. On pathologic examination, there was a patchy CD4 + T cell-dominant lymphoplasmacytic infiltration in the stroma, necrosis of the myofibrils and prominent perifascicular atrophy. Based on those findings, a diagnosis of clinically amyopathic dermatomyositis was made. Therapy with gamma-globulin was not effective in maintaining remission. In the sixth week after starting rituximab, she presented to emergency room with altered mental state from acute respiratory failure. Despite treatment with antibiotics, glucocorticoid pulse, cyclosporin, and polymyxin B-immobilized fiber column direct hemoperfusion, she died three weeks later from persistent hypoxemic respiratory failure.
CONCLUSIONS
This case showed the full spectrum and severity of internal organ involvement of dermatomyositis, although the patient presented exclusively with subcutaneous edema limited to the head. The prognosis may be more closely associated with a specific auto-antibody profile than the benign-looking initial clinical manifestation. Close follow-up of lung involvement with prophylactic treatment for Pneumocystis pneumonia and prompt implementation of emerging therapeutic regimens may improve the outcome.
Background
Even before the classification of dermatomyositis (DM) was defined by Bohan and Peter in 1975, it was well known that there was a subgroup of patients who did not have muscle disease, regarded as amyopathic dermatomyositis (ADM)[1]. Studies have shown that there is evidence of subclinical muscle disease in MRI imaging and muscle biopsy in ADM leading to the concept of clinically amyopathic dermatomyositis (CADM), which is defined as absence of clinical muscle disease on physical examination and muscle enzyme analysis for at least six months[2]. In CADM, which represents about 11–20 % of dermatomyositis (DM)[3, 4], the hallmark cutaneous manifestations such as Heliotrope rash, Gottron’s papules, and Gottron’s sign are the key to diagnosis.
There has been a report that suggested that subcutaneous edema is a cutaneous manifestation of DM because it can be the only skin lesion at presentation[5]. In the case series, edematous DM comprised 6 % (5/86) of a DM cohort. In the muscle biopsies of the five cases of edematous DM, there were frequent microinfarctions, which were considered to be induced by vasculitis producing micro-ischemia. In the reported five cases and review of 19 reported cases, there were six cases (3/5 and 3/19, respectively) in which subcutaneous edema was the sole cutaneous manifestation, but all had clinical muscle disease, suggesting that CADM presenting exclusively with subcutaneous edema is very rare. In this study, we report a case of CADM which presented with facial edema as the sole cutaneous manifestation and was later complicated by acute respiratory failure leading to mortality.
Case presentation
A 58-year-old woman presented with edema of the face that had developed approximately one year prior. It was not painful nor pruritic, but she felt it was more prominent on the left side. Courses of antibiotic therapy for a presumed diagnosis of cellulitis had not been effective, but glucocorticoids greatly improved the swelling, which relapsed rapidly with tapering. One week prior, as another course of glucocorticoids prescribed for a diagnosis of angioedema was tapered out, her facial edema relapsed, accompanied by tiny, pruritic vesicular lesions on the chin. Although she was evaluated in neurology and dental clinics, no specific diagnosis was made. She reported ‘dryness’ and ‘itchiness’ of the eyes, but not in the oral cavity.
On evaluation, there was bilateral swelling of the malar and temporal area of the face, involving the periorbital area and eyelid in the left side. On the chin, there was eczematoid vesicular eruption (Fig. 1a). There was no abnormal finding on the examination of the chest and abdomen. There was no edema or rash in the trunk or extremities. Neck flexion was preserved, and the power of the extremities’ motor function was evaluated as five on a scale of zero to five. On ophthalmologic examination, there was swelling of the left upper eyelid, and the anterior chamber was clear and deep in both eyes. Five-minute Schirmer test result was 6 mm in the right eye and 8 mm in the left eye (reference value < 5 mm for dry eye disease, but known to have low sensitivity in mild or moderate cases)[6]. Ocular staining score was 1 and 2 in the right and left eye, respectively (reference value ≥ 5 for classification of primary Sjögren’s syndrome)[7].
Fig. 1 Isolated facial edema and subclinical facial muscle involvement. At initial presentation there was bilateral swelling of the face and of the left eyelid, accompanied by eczematoid eruption on the chin (a). After approximately two weeks of medium-dose glucocorticoid therapy the edema and the lesions were completely resolved (b). However, combination therapy with either azathioprine, mycophenolate, or methotrexate was not successful in maintaining remission at a prednisolone dose lower than 15 mg per day. At the last relapse, there was marked aggravation of facial and eyelid edema (c). Gadolinium-enhanced MRI scan of the head shows diffuse edematous change with enhancement of bilateral masticator muscles (d, masseter muscle [yellow arrow] and lateral pterygoid muscle [black arrow]). There was also swelling of bilateral extra-ocular muscles and edematous change with fat infiltration in the subcutaneous tissues of the anterior scalp, periorbital area, buccal space, and anterior cervical fascia (not shown)
On the initial laboratory evaluation, there were no abnormalities, and the serum creatine phosphokinase (CPK) level was within normal range (Table 1). On serologic evaluation, antinuclear antibody was positive up to 1:160 in titer in homogeneous pattern, but anti-dsDNA Ab and anti-histone Ab was negative. Anti-SSA (> 240 U/mL) and anti-SSB (18 U/mL) antibodies were positive (fluorescent enzyme immunoassay, reference value < 7 U/mL for both); anti-RNP and anti-Smith Ab, negative. Anti-Jo1 antibody and anti-SRP antibody were negative. Anti-neutrophil cytoplasmic antibody was negative and IgG4 level was within normal range: 102 mg/dL (reference 30 ~ 201 mg/dL).
Table 1 Laboratory data
Variable Reference range At initial presentation At the second admission
WBC 4.0 ~ 10.0 × 109/L 5.2 2.84
RBC 4.2 ~ 5.4 × 1012/L 4.23 4.38
Hgb 12.0 ~ 16.0 g/dL 12.4 13.7
Platelet 140 ~ 440 × 109/L 230 166
Differential Count
Neutrophil 40 ~ 80 % 57.8 66.8
Lymphocyte 15 ~ 50 % 30.2 20.8
Monocyte 2 ~ 11 % 7.9 9.2
Eosinophil 0 ~ 7 % 3.5 2.8
Basophil 0 ~ 1 % 0.6 0.4
ESR ~ 120 mm 14 21
Total Protein 6.0 ~ 8.0 g/dl 7.4 7.1
Albumin 3.5 ~ 5.2 g/dl 4.3 4.1
Total Bilirubin ~ 1.2 mg/dl 0.64 1.01
AST 7 ~ 38 U/L 36 50
ALT 4 ~ 43 U/L 32 69
ALP 36 ~ 104 U/L 79 58
Glucose 70 ~ 110 mg/dl 84 109
Total Cholesterol ~ 200 mg/dl 171 204
BUN 6.0 ~ 20.0 mg/dl 16 18.6
Creatinine 0.6 ~ 1.2 mg/dl 0.79 0.82
Direct Bilirubin ~ 0.3 mg/dl 0.19 0.24
LDH ~ 250 IU/L 269 424
CPK 50 ~ 200 U/L 182 317
Uric acid 3.0 ~ 5.5 mg/dl 3.5 3.4
CRP ~ 0.30 mg/dL 0.05 0.68
WBC white blood cell, RBC red blood cell, ESR erythrocyte sedimentation rate, AST aspartate aminotransferase, ALT alanine aminotransferase, ALP alkaline phosphatase, BUN blood urea nitrogen, LDH lactase dehydrogenase, CPK creatine phosphokinase, CRP C-reactive protein
On MRI, there was a diffuse edematous change in the bilateral masticator and extra-ocular muscles, accompanied by subcutaneous fat infiltration in the buccal and periorbital spaces. There was inhomogeneous enhancement of bilateral parotid glands. On PET-CT scan there was diffuse F-18-FDG uptake in the periorbital, frontalis, temporalis, and masseter muscles and the buccal and submandibular spaces without any increased uptake in the extremities or internal organs.
The Head and Neck Surgery and Radiology departments opined that a biopsy of the muscles would entail risk of complications such as bleeding and injury to the muscles. After a discussion with the patient regarding undergoing a muscle biopsy, a presumptive clinical diagnosis of an overlap syndrome of Sjogren’s syndrome with myositis was made and treatment with a medium-dose glucocorticoid (prednisolone 30 mg/day) begun; based on reports of orbital involvement, a good response to therapy, and benign prognosis in myositis associated with Sjogren’s syndrome[8–10]. On 16th day of treatment, the facial swelling was assessed as having completely resolved (Fig. 1b); however, the facial edema relapsed during subsequent days when glucocorticoid doses were lowered to less than 15 mg/day. Combination therapy with azathioprine, mycophenolate, or methotrexate for eight months was not effective in maintaining remission at acceptable doses of glucocorticoid, and the swelling aggravated considerably with the final relapse.
The patient finally agreed to further evaluation and was admitted to the hospital. On examination, there was aggravation of the facial edema (Fig. 1c). There was swelling of the right ankle, without tenderness. Neck flexion was preserved and motor power of extremities was assessed as five on a scale of zero to five. On laboratory evaluation, there was mild elevation of liver transaminases and CPK (Table 1). Serum aldolase was 7.9 U/L (reference < 7.6 U/L). On MRI of the head, there was aggravation of the inflammation (Fig. 1d). On ultrasonography of the right ankle, there was subcutaneous edema without evidence of synovitis. A series of evaluations to screen for malignancy including tumor makers (CA19-9, CEA, and CA125), esophagogastroduodenoscopy, colonoscopy, and mammography did not reveal abnormal findings.
A US-guided core-needle biopsy with an 18-gauge needle was performed in the right masseter muscle. Two pieces of tiny muscle tissue, measuring up to 0.5 × 0.1 cm, were obtained. On pathologic examination, there was moderate size variation of the myofibers, and endomysial and perimysial fibrosis. There was patchy CD4 + T cell-dominant lymphoplasmacytic infiltration in the stroma and atrophy of the myofibers, mainly at the periphery of the fascicles, being consistent with perifascicular atrophy. Necrosis of the myofibers was not prominent (Fig. 2). Based on these findings, a diagnosis of clinically amyopathic dermatomyositis was made.
Fig. 2 Biopsy specimens from the right masseter muscle. Hematoxylin and eosin staining shows moderate size variation of the myofibers and endomysial and perimysial fibrosis (white arrow). There is atrophy of the myofibers, mainly at the periphery of the fascicles (black arrow), which is consistent with perifascicular atrophy (a). Patchy lymphoplasmacytic infiltration (white arrow) is noted in the stroma (b), which consists of predominantly more CD4-positive cells (c) than CD8-positive cells (d) in immunohistochemical staining. All figures are at 200-fold magnification
Therapy with gamma-globulin (IVIG, 2.1 g/kg per month) in combination with prednisolone 30 mg/day was initiated, and after the first cycle the facial edema had resolved completely. However, when the dose of prednisolone was decreased to 15 mg/day, she made an earlier visit to the clinic with a relapse of the facial edema within six days. By the fourth cycle of IVIG, sustained remission could not be achieved. A course of rituximab (1.0 g twice, a week apart) in combination with methylprednisolone 40 mg/day was started. In the sixth week of rituximab therapy, when glucocorticoid dose was decreased to methylprednisolone 32 mg/day, she presented to the emergency room with altered mentality that began one day prior. On presentation, there was a fever of 38.7 °C, and the patient began mechanical ventilation immediately for hypoxemic respiratory failure. On chest X-ray, there was diffuse consolidation in both lung fields (Fig. 3b). On high-resolution CT, there was diffuse consolidation in the dependent portion of the lungs and diffuse ground glass opacity with relative sparing of the base of the lungs (Fig. 3c, d). The next day, the patient underwent bronchoscopy with bronchoalveolar lavage. The total cell count was 12 × 106 cells in 9 mL of fluid. Differential data of each cell type was as follows: macrophage 8 %, neutrophil 83 %, and lymphocyte 9 %. There was no bacteria isolated from the respiratory specimen, and a polymerase chain reaction (PCR) test for respiratory viruses including adenovirus, influenza virus, parainfluenza virus, and respiratory syncytial virus was negative. Pneumocystis jirovecii PCR and Gomori methenamine silver (GMS) staining were positive, and the patient began treatment with trimethoprim-sulfamethoxazole and glucocorticoids; but her hypoxemic respiratory failure progressed, and veno-venous extracorporeal (ECMO) membrane oxygenation was begun three days later. Given the lack of response to antibiotics therapy, glucocorticoid pulse and IV cyclosporine was started in consideration of rapidly progressive interstitial lung disease (RP-ILD). Over the next three weeks, despite the addition of polymyxin B-immobilized fiber column direct hemoperfusion (PMX-DHP)[11], there was no improvement in her hypoxemic respiratory failure, and according to the family’s will, the ECMO was weaned. On that day, she expired from respiratory failure.
Fig. 3 Chest radiographic images before and at the presentation of acute respiratory failure. Chest postero-anterior radiography taken about one month after initiating rituximab therapy shows no clear haziness or infiltration in both lung fields (a). At the presentation of acute respiratory failure with altered mentality (in the sixth week after starting rituximab) there was diffuse bilateral infiltration in both lung fields with relative sparing of both lower lung fields (b). Axial high-resolution computed tomography images show diffuse ground glass opacity in both upper lungs with consolidation in dependent areas (c); The lung base is relatively spared (d)
Discussion and Conclusions
This case, which posed significant diagnostic and therapeutic challenges, leaves important lessons for practice and research. First, isolated localized edema may be the initial manifestation of CADM. Such a case is considered very rare; we could find only one case reported in sufficient detail for us to verify the absence of muscle disease and other cutaneous manifestations, the prognosis of which was not known[12]. Second, although the patient presented initially with mild glucocorticoid-responsive facial edema, her course showed increasing extent of subcutaneous edema, decreasing response to immunomodulating therapy, and acute and severe involvement of the lungs leading to death. This suggests the prognosis cannot be predicted by the initially mild clinical manifestation alone.
Severe respiratory complications in idiopathic inflammatory myopathies such as DM pose considerable challenges to treatment, and the prognosis is poor[13, 14]. Differential diagnoses include cardiac complications, respiratory muscle weakness, drug hypersensitivity, RP-ILD, and severe and opportunistic infections[15, 16]. In many cases, it is difficult to arrive at a specific diagnosis, and there is a therapeutic dilemma of treating a severe autoimmune inflammation and a difficult-to-treat infection at the same time. Also in this case, there are a couple of explanations for the acute respiratory disease. First, the possibility of Pneumocystis pneumonia (PCP) should be considered. Prolonged glucocorticoid therapy is one of the risk factors for PCP in patients undergoing immunomodulating therapy for systemic autoimmune rheumatic diseases, and the patient was not receiving prophylaxis for it because of thrombocytopenia (< 50,000/mm3). Radiographic findings of acutely developed consolidation and ground glass opacity with relative sparing of the lung base is suggestive of PCP, and PCR and GMS staining were positive. In addition, even with appropriate treatment, mortality in fulminant PCP in non-HIV immunocompromised patients is high; in a recent study, the mortality rate in idiopathic inflammatory myopathy (including CADM) patients admitted to ICUs was 79.4 %, and PCP comprised approximately 20 % of the admissions[13]. Second, we believe the possibility of RP-ILD should be considered. From the early 2000s, associations between CADM and RP-ILD with poor prognosis were reported in Northeast Asia, including Korea, with mortality reaching approximately 50 %[17–19]. Later studies identified an association between anti-melanoma differentiation-associated protein 5 (MDA5) antibody and RP-ILD[20] [21], both of which are more common in CADM than in DM[22], and in Asians compared with Caucasians[21]. Recent studies report initial combination immunosuppressive therapies improved survival in RP-ILD in CADM[23], and that in the case of refractories a rescue therapy with tofacitinib may improve the outcome[24, 25]. Although we could not evaluate the presence of anti-MDA5 Ab in this case, which is a limitation of this study, rapidly progressive ILD was a possibility in the differential diagnosis of acute respiratory failure which did not respond to antibiotic therapy. Third, rituximab-induced lung disease could be considered. The patient developed acute respiratory symptoms five weeks and one day after the last rituximab infusion. This was in the period when late-onset respiratory illness may develop after rituximab infusion. However, late-onset rituximab-induced respiratory illness is less frequent than delayed-onset illness, shows a chronic course over weeks or months, and responds well to glucocorticoid therapy[26].
In conclusion, this case showed that CADM can initially manifest as a localized subcutaneous edema as the sole cutaneous manifestation but follow a progressive, refractory, and fatal course with major organ involvement, especially involving the lungs. A specific auto-antibody pattern may better predict the prognosis. Identification of the specific antibody profile and prompt initiation of therapy with proven efficacy may improve the outcome.
Authors’ contributions.
DHL analyzed clinical data and prepared the manuscript. YMK performed pathologic examination of the muscle biopsy samples and wrote the pathologic results. JHR performed the radiologic examination and muscle biopsy and contributed to writing. JHL, CSP, and SHK participated in critical care of the patient and contributed to writing. SL planned the study and performed analysis of data and literature. All authors read and approved the final manuscript.
Publisher’s Note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
Acknowledgements
Not applicable.
Authors' contributions
DHL analyzed clinical data and prepared the manuscript. YMK performed pathologic examination of the muscle biopsy samples and wrote the pathologic results. JHR performed the radiologic examination and muscle biopsy and contributed to writing. JHL, CSP, and SHK participated in critical care of the patient and contributed to writing. SL planned the study and performed analysis of data and literature. All authors read and approved the final manuscript.
Funding
Not applicable.
Availability of data and materials
Not applicable.
Ethics approval and consent to participate
This study was approved by the institutional review board of Haeundae Paik hospital (IRB file number: HPIRB 2019-08-016-001).
Consent for publication
Written informed consent was obtained from the patient, including the use of photographs of the face.
Competing interests
The authors declare that they have no competing interests. | HUMAN IMMUNOGLOBULIN G, METHYLPREDNISOLONE, PREDNISONE, RITUXIMAB | DrugsGivenReaction | CC BY | 33509162 | 18,862,926 | 2021-01-28 |
Give an alphabetized list of all active substances of drugs taken by the patient who experienced 'Drug ineffective'. | Clinically amyopathic dermatomyositis presenting with isolated facial edema complicated by acute respiratory failure: a case report.
BACKGROUND
In clinically amyopathic dermatomyositis, the hallmark cutaneous manifestations are the key to diagnosis. We report a case of clinically amyopathic dermatomyositis which presented with facial edema as the sole cutaneous manifestation and was later complicated by acute respiratory failure leading to death.
METHODS
A 58-year-old woman presented with edema of the face that had developed approximately one year ago. There was no weakness in the extremities, and the serum creatine kinase level was within normal range. On MRI, there was diffuse edematous change in the bilateral masticator and extra-ocular muscles, accompanied by subcutaneous fat infiltration in the face. A shared decision was made to defer muscle biopsy in the facial muscles. The facial swelling almost resolved with medium-dose glucocorticoid therapy but relapsed in days at glucocorticoid doses lower than 15 mg/day. Combination therapy with either azathioprine, mycophenolate, or methotrexate was not successful in maintaining clinical remission, and the swelling became more severe after relapses. A US-guided core-needle biopsy was subsequently performed in the right masseter muscle. On pathologic examination, there was a patchy CD4 + T cell-dominant lymphoplasmacytic infiltration in the stroma, necrosis of the myofibrils and prominent perifascicular atrophy. Based on those findings, a diagnosis of clinically amyopathic dermatomyositis was made. Therapy with gamma-globulin was not effective in maintaining remission. In the sixth week after starting rituximab, she presented to emergency room with altered mental state from acute respiratory failure. Despite treatment with antibiotics, glucocorticoid pulse, cyclosporin, and polymyxin B-immobilized fiber column direct hemoperfusion, she died three weeks later from persistent hypoxemic respiratory failure.
CONCLUSIONS
This case showed the full spectrum and severity of internal organ involvement of dermatomyositis, although the patient presented exclusively with subcutaneous edema limited to the head. The prognosis may be more closely associated with a specific auto-antibody profile than the benign-looking initial clinical manifestation. Close follow-up of lung involvement with prophylactic treatment for Pneumocystis pneumonia and prompt implementation of emerging therapeutic regimens may improve the outcome.
Background
Even before the classification of dermatomyositis (DM) was defined by Bohan and Peter in 1975, it was well known that there was a subgroup of patients who did not have muscle disease, regarded as amyopathic dermatomyositis (ADM)[1]. Studies have shown that there is evidence of subclinical muscle disease in MRI imaging and muscle biopsy in ADM leading to the concept of clinically amyopathic dermatomyositis (CADM), which is defined as absence of clinical muscle disease on physical examination and muscle enzyme analysis for at least six months[2]. In CADM, which represents about 11–20 % of dermatomyositis (DM)[3, 4], the hallmark cutaneous manifestations such as Heliotrope rash, Gottron’s papules, and Gottron’s sign are the key to diagnosis.
There has been a report that suggested that subcutaneous edema is a cutaneous manifestation of DM because it can be the only skin lesion at presentation[5]. In the case series, edematous DM comprised 6 % (5/86) of a DM cohort. In the muscle biopsies of the five cases of edematous DM, there were frequent microinfarctions, which were considered to be induced by vasculitis producing micro-ischemia. In the reported five cases and review of 19 reported cases, there were six cases (3/5 and 3/19, respectively) in which subcutaneous edema was the sole cutaneous manifestation, but all had clinical muscle disease, suggesting that CADM presenting exclusively with subcutaneous edema is very rare. In this study, we report a case of CADM which presented with facial edema as the sole cutaneous manifestation and was later complicated by acute respiratory failure leading to mortality.
Case presentation
A 58-year-old woman presented with edema of the face that had developed approximately one year prior. It was not painful nor pruritic, but she felt it was more prominent on the left side. Courses of antibiotic therapy for a presumed diagnosis of cellulitis had not been effective, but glucocorticoids greatly improved the swelling, which relapsed rapidly with tapering. One week prior, as another course of glucocorticoids prescribed for a diagnosis of angioedema was tapered out, her facial edema relapsed, accompanied by tiny, pruritic vesicular lesions on the chin. Although she was evaluated in neurology and dental clinics, no specific diagnosis was made. She reported ‘dryness’ and ‘itchiness’ of the eyes, but not in the oral cavity.
On evaluation, there was bilateral swelling of the malar and temporal area of the face, involving the periorbital area and eyelid in the left side. On the chin, there was eczematoid vesicular eruption (Fig. 1a). There was no abnormal finding on the examination of the chest and abdomen. There was no edema or rash in the trunk or extremities. Neck flexion was preserved, and the power of the extremities’ motor function was evaluated as five on a scale of zero to five. On ophthalmologic examination, there was swelling of the left upper eyelid, and the anterior chamber was clear and deep in both eyes. Five-minute Schirmer test result was 6 mm in the right eye and 8 mm in the left eye (reference value < 5 mm for dry eye disease, but known to have low sensitivity in mild or moderate cases)[6]. Ocular staining score was 1 and 2 in the right and left eye, respectively (reference value ≥ 5 for classification of primary Sjögren’s syndrome)[7].
Fig. 1 Isolated facial edema and subclinical facial muscle involvement. At initial presentation there was bilateral swelling of the face and of the left eyelid, accompanied by eczematoid eruption on the chin (a). After approximately two weeks of medium-dose glucocorticoid therapy the edema and the lesions were completely resolved (b). However, combination therapy with either azathioprine, mycophenolate, or methotrexate was not successful in maintaining remission at a prednisolone dose lower than 15 mg per day. At the last relapse, there was marked aggravation of facial and eyelid edema (c). Gadolinium-enhanced MRI scan of the head shows diffuse edematous change with enhancement of bilateral masticator muscles (d, masseter muscle [yellow arrow] and lateral pterygoid muscle [black arrow]). There was also swelling of bilateral extra-ocular muscles and edematous change with fat infiltration in the subcutaneous tissues of the anterior scalp, periorbital area, buccal space, and anterior cervical fascia (not shown)
On the initial laboratory evaluation, there were no abnormalities, and the serum creatine phosphokinase (CPK) level was within normal range (Table 1). On serologic evaluation, antinuclear antibody was positive up to 1:160 in titer in homogeneous pattern, but anti-dsDNA Ab and anti-histone Ab was negative. Anti-SSA (> 240 U/mL) and anti-SSB (18 U/mL) antibodies were positive (fluorescent enzyme immunoassay, reference value < 7 U/mL for both); anti-RNP and anti-Smith Ab, negative. Anti-Jo1 antibody and anti-SRP antibody were negative. Anti-neutrophil cytoplasmic antibody was negative and IgG4 level was within normal range: 102 mg/dL (reference 30 ~ 201 mg/dL).
Table 1 Laboratory data
Variable Reference range At initial presentation At the second admission
WBC 4.0 ~ 10.0 × 109/L 5.2 2.84
RBC 4.2 ~ 5.4 × 1012/L 4.23 4.38
Hgb 12.0 ~ 16.0 g/dL 12.4 13.7
Platelet 140 ~ 440 × 109/L 230 166
Differential Count
Neutrophil 40 ~ 80 % 57.8 66.8
Lymphocyte 15 ~ 50 % 30.2 20.8
Monocyte 2 ~ 11 % 7.9 9.2
Eosinophil 0 ~ 7 % 3.5 2.8
Basophil 0 ~ 1 % 0.6 0.4
ESR ~ 120 mm 14 21
Total Protein 6.0 ~ 8.0 g/dl 7.4 7.1
Albumin 3.5 ~ 5.2 g/dl 4.3 4.1
Total Bilirubin ~ 1.2 mg/dl 0.64 1.01
AST 7 ~ 38 U/L 36 50
ALT 4 ~ 43 U/L 32 69
ALP 36 ~ 104 U/L 79 58
Glucose 70 ~ 110 mg/dl 84 109
Total Cholesterol ~ 200 mg/dl 171 204
BUN 6.0 ~ 20.0 mg/dl 16 18.6
Creatinine 0.6 ~ 1.2 mg/dl 0.79 0.82
Direct Bilirubin ~ 0.3 mg/dl 0.19 0.24
LDH ~ 250 IU/L 269 424
CPK 50 ~ 200 U/L 182 317
Uric acid 3.0 ~ 5.5 mg/dl 3.5 3.4
CRP ~ 0.30 mg/dL 0.05 0.68
WBC white blood cell, RBC red blood cell, ESR erythrocyte sedimentation rate, AST aspartate aminotransferase, ALT alanine aminotransferase, ALP alkaline phosphatase, BUN blood urea nitrogen, LDH lactase dehydrogenase, CPK creatine phosphokinase, CRP C-reactive protein
On MRI, there was a diffuse edematous change in the bilateral masticator and extra-ocular muscles, accompanied by subcutaneous fat infiltration in the buccal and periorbital spaces. There was inhomogeneous enhancement of bilateral parotid glands. On PET-CT scan there was diffuse F-18-FDG uptake in the periorbital, frontalis, temporalis, and masseter muscles and the buccal and submandibular spaces without any increased uptake in the extremities or internal organs.
The Head and Neck Surgery and Radiology departments opined that a biopsy of the muscles would entail risk of complications such as bleeding and injury to the muscles. After a discussion with the patient regarding undergoing a muscle biopsy, a presumptive clinical diagnosis of an overlap syndrome of Sjogren’s syndrome with myositis was made and treatment with a medium-dose glucocorticoid (prednisolone 30 mg/day) begun; based on reports of orbital involvement, a good response to therapy, and benign prognosis in myositis associated with Sjogren’s syndrome[8–10]. On 16th day of treatment, the facial swelling was assessed as having completely resolved (Fig. 1b); however, the facial edema relapsed during subsequent days when glucocorticoid doses were lowered to less than 15 mg/day. Combination therapy with azathioprine, mycophenolate, or methotrexate for eight months was not effective in maintaining remission at acceptable doses of glucocorticoid, and the swelling aggravated considerably with the final relapse.
The patient finally agreed to further evaluation and was admitted to the hospital. On examination, there was aggravation of the facial edema (Fig. 1c). There was swelling of the right ankle, without tenderness. Neck flexion was preserved and motor power of extremities was assessed as five on a scale of zero to five. On laboratory evaluation, there was mild elevation of liver transaminases and CPK (Table 1). Serum aldolase was 7.9 U/L (reference < 7.6 U/L). On MRI of the head, there was aggravation of the inflammation (Fig. 1d). On ultrasonography of the right ankle, there was subcutaneous edema without evidence of synovitis. A series of evaluations to screen for malignancy including tumor makers (CA19-9, CEA, and CA125), esophagogastroduodenoscopy, colonoscopy, and mammography did not reveal abnormal findings.
A US-guided core-needle biopsy with an 18-gauge needle was performed in the right masseter muscle. Two pieces of tiny muscle tissue, measuring up to 0.5 × 0.1 cm, were obtained. On pathologic examination, there was moderate size variation of the myofibers, and endomysial and perimysial fibrosis. There was patchy CD4 + T cell-dominant lymphoplasmacytic infiltration in the stroma and atrophy of the myofibers, mainly at the periphery of the fascicles, being consistent with perifascicular atrophy. Necrosis of the myofibers was not prominent (Fig. 2). Based on these findings, a diagnosis of clinically amyopathic dermatomyositis was made.
Fig. 2 Biopsy specimens from the right masseter muscle. Hematoxylin and eosin staining shows moderate size variation of the myofibers and endomysial and perimysial fibrosis (white arrow). There is atrophy of the myofibers, mainly at the periphery of the fascicles (black arrow), which is consistent with perifascicular atrophy (a). Patchy lymphoplasmacytic infiltration (white arrow) is noted in the stroma (b), which consists of predominantly more CD4-positive cells (c) than CD8-positive cells (d) in immunohistochemical staining. All figures are at 200-fold magnification
Therapy with gamma-globulin (IVIG, 2.1 g/kg per month) in combination with prednisolone 30 mg/day was initiated, and after the first cycle the facial edema had resolved completely. However, when the dose of prednisolone was decreased to 15 mg/day, she made an earlier visit to the clinic with a relapse of the facial edema within six days. By the fourth cycle of IVIG, sustained remission could not be achieved. A course of rituximab (1.0 g twice, a week apart) in combination with methylprednisolone 40 mg/day was started. In the sixth week of rituximab therapy, when glucocorticoid dose was decreased to methylprednisolone 32 mg/day, she presented to the emergency room with altered mentality that began one day prior. On presentation, there was a fever of 38.7 °C, and the patient began mechanical ventilation immediately for hypoxemic respiratory failure. On chest X-ray, there was diffuse consolidation in both lung fields (Fig. 3b). On high-resolution CT, there was diffuse consolidation in the dependent portion of the lungs and diffuse ground glass opacity with relative sparing of the base of the lungs (Fig. 3c, d). The next day, the patient underwent bronchoscopy with bronchoalveolar lavage. The total cell count was 12 × 106 cells in 9 mL of fluid. Differential data of each cell type was as follows: macrophage 8 %, neutrophil 83 %, and lymphocyte 9 %. There was no bacteria isolated from the respiratory specimen, and a polymerase chain reaction (PCR) test for respiratory viruses including adenovirus, influenza virus, parainfluenza virus, and respiratory syncytial virus was negative. Pneumocystis jirovecii PCR and Gomori methenamine silver (GMS) staining were positive, and the patient began treatment with trimethoprim-sulfamethoxazole and glucocorticoids; but her hypoxemic respiratory failure progressed, and veno-venous extracorporeal (ECMO) membrane oxygenation was begun three days later. Given the lack of response to antibiotics therapy, glucocorticoid pulse and IV cyclosporine was started in consideration of rapidly progressive interstitial lung disease (RP-ILD). Over the next three weeks, despite the addition of polymyxin B-immobilized fiber column direct hemoperfusion (PMX-DHP)[11], there was no improvement in her hypoxemic respiratory failure, and according to the family’s will, the ECMO was weaned. On that day, she expired from respiratory failure.
Fig. 3 Chest radiographic images before and at the presentation of acute respiratory failure. Chest postero-anterior radiography taken about one month after initiating rituximab therapy shows no clear haziness or infiltration in both lung fields (a). At the presentation of acute respiratory failure with altered mentality (in the sixth week after starting rituximab) there was diffuse bilateral infiltration in both lung fields with relative sparing of both lower lung fields (b). Axial high-resolution computed tomography images show diffuse ground glass opacity in both upper lungs with consolidation in dependent areas (c); The lung base is relatively spared (d)
Discussion and Conclusions
This case, which posed significant diagnostic and therapeutic challenges, leaves important lessons for practice and research. First, isolated localized edema may be the initial manifestation of CADM. Such a case is considered very rare; we could find only one case reported in sufficient detail for us to verify the absence of muscle disease and other cutaneous manifestations, the prognosis of which was not known[12]. Second, although the patient presented initially with mild glucocorticoid-responsive facial edema, her course showed increasing extent of subcutaneous edema, decreasing response to immunomodulating therapy, and acute and severe involvement of the lungs leading to death. This suggests the prognosis cannot be predicted by the initially mild clinical manifestation alone.
Severe respiratory complications in idiopathic inflammatory myopathies such as DM pose considerable challenges to treatment, and the prognosis is poor[13, 14]. Differential diagnoses include cardiac complications, respiratory muscle weakness, drug hypersensitivity, RP-ILD, and severe and opportunistic infections[15, 16]. In many cases, it is difficult to arrive at a specific diagnosis, and there is a therapeutic dilemma of treating a severe autoimmune inflammation and a difficult-to-treat infection at the same time. Also in this case, there are a couple of explanations for the acute respiratory disease. First, the possibility of Pneumocystis pneumonia (PCP) should be considered. Prolonged glucocorticoid therapy is one of the risk factors for PCP in patients undergoing immunomodulating therapy for systemic autoimmune rheumatic diseases, and the patient was not receiving prophylaxis for it because of thrombocytopenia (< 50,000/mm3). Radiographic findings of acutely developed consolidation and ground glass opacity with relative sparing of the lung base is suggestive of PCP, and PCR and GMS staining were positive. In addition, even with appropriate treatment, mortality in fulminant PCP in non-HIV immunocompromised patients is high; in a recent study, the mortality rate in idiopathic inflammatory myopathy (including CADM) patients admitted to ICUs was 79.4 %, and PCP comprised approximately 20 % of the admissions[13]. Second, we believe the possibility of RP-ILD should be considered. From the early 2000s, associations between CADM and RP-ILD with poor prognosis were reported in Northeast Asia, including Korea, with mortality reaching approximately 50 %[17–19]. Later studies identified an association between anti-melanoma differentiation-associated protein 5 (MDA5) antibody and RP-ILD[20] [21], both of which are more common in CADM than in DM[22], and in Asians compared with Caucasians[21]. Recent studies report initial combination immunosuppressive therapies improved survival in RP-ILD in CADM[23], and that in the case of refractories a rescue therapy with tofacitinib may improve the outcome[24, 25]. Although we could not evaluate the presence of anti-MDA5 Ab in this case, which is a limitation of this study, rapidly progressive ILD was a possibility in the differential diagnosis of acute respiratory failure which did not respond to antibiotic therapy. Third, rituximab-induced lung disease could be considered. The patient developed acute respiratory symptoms five weeks and one day after the last rituximab infusion. This was in the period when late-onset respiratory illness may develop after rituximab infusion. However, late-onset rituximab-induced respiratory illness is less frequent than delayed-onset illness, shows a chronic course over weeks or months, and responds well to glucocorticoid therapy[26].
In conclusion, this case showed that CADM can initially manifest as a localized subcutaneous edema as the sole cutaneous manifestation but follow a progressive, refractory, and fatal course with major organ involvement, especially involving the lungs. A specific auto-antibody pattern may better predict the prognosis. Identification of the specific antibody profile and prompt initiation of therapy with proven efficacy may improve the outcome.
Authors’ contributions.
DHL analyzed clinical data and prepared the manuscript. YMK performed pathologic examination of the muscle biopsy samples and wrote the pathologic results. JHR performed the radiologic examination and muscle biopsy and contributed to writing. JHL, CSP, and SHK participated in critical care of the patient and contributed to writing. SL planned the study and performed analysis of data and literature. All authors read and approved the final manuscript.
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Acknowledgements
Not applicable.
Authors' contributions
DHL analyzed clinical data and prepared the manuscript. YMK performed pathologic examination of the muscle biopsy samples and wrote the pathologic results. JHR performed the radiologic examination and muscle biopsy and contributed to writing. JHL, CSP, and SHK participated in critical care of the patient and contributed to writing. SL planned the study and performed analysis of data and literature. All authors read and approved the final manuscript.
Funding
Not applicable.
Availability of data and materials
Not applicable.
Ethics approval and consent to participate
This study was approved by the institutional review board of Haeundae Paik hospital (IRB file number: HPIRB 2019-08-016-001).
Consent for publication
Written informed consent was obtained from the patient, including the use of photographs of the face.
Competing interests
The authors declare that they have no competing interests. | AZATHIOPRINE, METHOTREXATE, METHYLPREDNISOLONE, MYCOPHENOLATE MOFETIL, PREDNISOLONE, RITUXIMAB | DrugsGivenReaction | CC BY | 33509162 | 19,217,583 | 2021-01-28 |
Give an alphabetized list of all active substances of drugs taken by the patient who experienced 'Interstitial lung disease'. | Clinically amyopathic dermatomyositis presenting with isolated facial edema complicated by acute respiratory failure: a case report.
BACKGROUND
In clinically amyopathic dermatomyositis, the hallmark cutaneous manifestations are the key to diagnosis. We report a case of clinically amyopathic dermatomyositis which presented with facial edema as the sole cutaneous manifestation and was later complicated by acute respiratory failure leading to death.
METHODS
A 58-year-old woman presented with edema of the face that had developed approximately one year ago. There was no weakness in the extremities, and the serum creatine kinase level was within normal range. On MRI, there was diffuse edematous change in the bilateral masticator and extra-ocular muscles, accompanied by subcutaneous fat infiltration in the face. A shared decision was made to defer muscle biopsy in the facial muscles. The facial swelling almost resolved with medium-dose glucocorticoid therapy but relapsed in days at glucocorticoid doses lower than 15 mg/day. Combination therapy with either azathioprine, mycophenolate, or methotrexate was not successful in maintaining clinical remission, and the swelling became more severe after relapses. A US-guided core-needle biopsy was subsequently performed in the right masseter muscle. On pathologic examination, there was a patchy CD4 + T cell-dominant lymphoplasmacytic infiltration in the stroma, necrosis of the myofibrils and prominent perifascicular atrophy. Based on those findings, a diagnosis of clinically amyopathic dermatomyositis was made. Therapy with gamma-globulin was not effective in maintaining remission. In the sixth week after starting rituximab, she presented to emergency room with altered mental state from acute respiratory failure. Despite treatment with antibiotics, glucocorticoid pulse, cyclosporin, and polymyxin B-immobilized fiber column direct hemoperfusion, she died three weeks later from persistent hypoxemic respiratory failure.
CONCLUSIONS
This case showed the full spectrum and severity of internal organ involvement of dermatomyositis, although the patient presented exclusively with subcutaneous edema limited to the head. The prognosis may be more closely associated with a specific auto-antibody profile than the benign-looking initial clinical manifestation. Close follow-up of lung involvement with prophylactic treatment for Pneumocystis pneumonia and prompt implementation of emerging therapeutic regimens may improve the outcome.
Background
Even before the classification of dermatomyositis (DM) was defined by Bohan and Peter in 1975, it was well known that there was a subgroup of patients who did not have muscle disease, regarded as amyopathic dermatomyositis (ADM)[1]. Studies have shown that there is evidence of subclinical muscle disease in MRI imaging and muscle biopsy in ADM leading to the concept of clinically amyopathic dermatomyositis (CADM), which is defined as absence of clinical muscle disease on physical examination and muscle enzyme analysis for at least six months[2]. In CADM, which represents about 11–20 % of dermatomyositis (DM)[3, 4], the hallmark cutaneous manifestations such as Heliotrope rash, Gottron’s papules, and Gottron’s sign are the key to diagnosis.
There has been a report that suggested that subcutaneous edema is a cutaneous manifestation of DM because it can be the only skin lesion at presentation[5]. In the case series, edematous DM comprised 6 % (5/86) of a DM cohort. In the muscle biopsies of the five cases of edematous DM, there were frequent microinfarctions, which were considered to be induced by vasculitis producing micro-ischemia. In the reported five cases and review of 19 reported cases, there were six cases (3/5 and 3/19, respectively) in which subcutaneous edema was the sole cutaneous manifestation, but all had clinical muscle disease, suggesting that CADM presenting exclusively with subcutaneous edema is very rare. In this study, we report a case of CADM which presented with facial edema as the sole cutaneous manifestation and was later complicated by acute respiratory failure leading to mortality.
Case presentation
A 58-year-old woman presented with edema of the face that had developed approximately one year prior. It was not painful nor pruritic, but she felt it was more prominent on the left side. Courses of antibiotic therapy for a presumed diagnosis of cellulitis had not been effective, but glucocorticoids greatly improved the swelling, which relapsed rapidly with tapering. One week prior, as another course of glucocorticoids prescribed for a diagnosis of angioedema was tapered out, her facial edema relapsed, accompanied by tiny, pruritic vesicular lesions on the chin. Although she was evaluated in neurology and dental clinics, no specific diagnosis was made. She reported ‘dryness’ and ‘itchiness’ of the eyes, but not in the oral cavity.
On evaluation, there was bilateral swelling of the malar and temporal area of the face, involving the periorbital area and eyelid in the left side. On the chin, there was eczematoid vesicular eruption (Fig. 1a). There was no abnormal finding on the examination of the chest and abdomen. There was no edema or rash in the trunk or extremities. Neck flexion was preserved, and the power of the extremities’ motor function was evaluated as five on a scale of zero to five. On ophthalmologic examination, there was swelling of the left upper eyelid, and the anterior chamber was clear and deep in both eyes. Five-minute Schirmer test result was 6 mm in the right eye and 8 mm in the left eye (reference value < 5 mm for dry eye disease, but known to have low sensitivity in mild or moderate cases)[6]. Ocular staining score was 1 and 2 in the right and left eye, respectively (reference value ≥ 5 for classification of primary Sjögren’s syndrome)[7].
Fig. 1 Isolated facial edema and subclinical facial muscle involvement. At initial presentation there was bilateral swelling of the face and of the left eyelid, accompanied by eczematoid eruption on the chin (a). After approximately two weeks of medium-dose glucocorticoid therapy the edema and the lesions were completely resolved (b). However, combination therapy with either azathioprine, mycophenolate, or methotrexate was not successful in maintaining remission at a prednisolone dose lower than 15 mg per day. At the last relapse, there was marked aggravation of facial and eyelid edema (c). Gadolinium-enhanced MRI scan of the head shows diffuse edematous change with enhancement of bilateral masticator muscles (d, masseter muscle [yellow arrow] and lateral pterygoid muscle [black arrow]). There was also swelling of bilateral extra-ocular muscles and edematous change with fat infiltration in the subcutaneous tissues of the anterior scalp, periorbital area, buccal space, and anterior cervical fascia (not shown)
On the initial laboratory evaluation, there were no abnormalities, and the serum creatine phosphokinase (CPK) level was within normal range (Table 1). On serologic evaluation, antinuclear antibody was positive up to 1:160 in titer in homogeneous pattern, but anti-dsDNA Ab and anti-histone Ab was negative. Anti-SSA (> 240 U/mL) and anti-SSB (18 U/mL) antibodies were positive (fluorescent enzyme immunoassay, reference value < 7 U/mL for both); anti-RNP and anti-Smith Ab, negative. Anti-Jo1 antibody and anti-SRP antibody were negative. Anti-neutrophil cytoplasmic antibody was negative and IgG4 level was within normal range: 102 mg/dL (reference 30 ~ 201 mg/dL).
Table 1 Laboratory data
Variable Reference range At initial presentation At the second admission
WBC 4.0 ~ 10.0 × 109/L 5.2 2.84
RBC 4.2 ~ 5.4 × 1012/L 4.23 4.38
Hgb 12.0 ~ 16.0 g/dL 12.4 13.7
Platelet 140 ~ 440 × 109/L 230 166
Differential Count
Neutrophil 40 ~ 80 % 57.8 66.8
Lymphocyte 15 ~ 50 % 30.2 20.8
Monocyte 2 ~ 11 % 7.9 9.2
Eosinophil 0 ~ 7 % 3.5 2.8
Basophil 0 ~ 1 % 0.6 0.4
ESR ~ 120 mm 14 21
Total Protein 6.0 ~ 8.0 g/dl 7.4 7.1
Albumin 3.5 ~ 5.2 g/dl 4.3 4.1
Total Bilirubin ~ 1.2 mg/dl 0.64 1.01
AST 7 ~ 38 U/L 36 50
ALT 4 ~ 43 U/L 32 69
ALP 36 ~ 104 U/L 79 58
Glucose 70 ~ 110 mg/dl 84 109
Total Cholesterol ~ 200 mg/dl 171 204
BUN 6.0 ~ 20.0 mg/dl 16 18.6
Creatinine 0.6 ~ 1.2 mg/dl 0.79 0.82
Direct Bilirubin ~ 0.3 mg/dl 0.19 0.24
LDH ~ 250 IU/L 269 424
CPK 50 ~ 200 U/L 182 317
Uric acid 3.0 ~ 5.5 mg/dl 3.5 3.4
CRP ~ 0.30 mg/dL 0.05 0.68
WBC white blood cell, RBC red blood cell, ESR erythrocyte sedimentation rate, AST aspartate aminotransferase, ALT alanine aminotransferase, ALP alkaline phosphatase, BUN blood urea nitrogen, LDH lactase dehydrogenase, CPK creatine phosphokinase, CRP C-reactive protein
On MRI, there was a diffuse edematous change in the bilateral masticator and extra-ocular muscles, accompanied by subcutaneous fat infiltration in the buccal and periorbital spaces. There was inhomogeneous enhancement of bilateral parotid glands. On PET-CT scan there was diffuse F-18-FDG uptake in the periorbital, frontalis, temporalis, and masseter muscles and the buccal and submandibular spaces without any increased uptake in the extremities or internal organs.
The Head and Neck Surgery and Radiology departments opined that a biopsy of the muscles would entail risk of complications such as bleeding and injury to the muscles. After a discussion with the patient regarding undergoing a muscle biopsy, a presumptive clinical diagnosis of an overlap syndrome of Sjogren’s syndrome with myositis was made and treatment with a medium-dose glucocorticoid (prednisolone 30 mg/day) begun; based on reports of orbital involvement, a good response to therapy, and benign prognosis in myositis associated with Sjogren’s syndrome[8–10]. On 16th day of treatment, the facial swelling was assessed as having completely resolved (Fig. 1b); however, the facial edema relapsed during subsequent days when glucocorticoid doses were lowered to less than 15 mg/day. Combination therapy with azathioprine, mycophenolate, or methotrexate for eight months was not effective in maintaining remission at acceptable doses of glucocorticoid, and the swelling aggravated considerably with the final relapse.
The patient finally agreed to further evaluation and was admitted to the hospital. On examination, there was aggravation of the facial edema (Fig. 1c). There was swelling of the right ankle, without tenderness. Neck flexion was preserved and motor power of extremities was assessed as five on a scale of zero to five. On laboratory evaluation, there was mild elevation of liver transaminases and CPK (Table 1). Serum aldolase was 7.9 U/L (reference < 7.6 U/L). On MRI of the head, there was aggravation of the inflammation (Fig. 1d). On ultrasonography of the right ankle, there was subcutaneous edema without evidence of synovitis. A series of evaluations to screen for malignancy including tumor makers (CA19-9, CEA, and CA125), esophagogastroduodenoscopy, colonoscopy, and mammography did not reveal abnormal findings.
A US-guided core-needle biopsy with an 18-gauge needle was performed in the right masseter muscle. Two pieces of tiny muscle tissue, measuring up to 0.5 × 0.1 cm, were obtained. On pathologic examination, there was moderate size variation of the myofibers, and endomysial and perimysial fibrosis. There was patchy CD4 + T cell-dominant lymphoplasmacytic infiltration in the stroma and atrophy of the myofibers, mainly at the periphery of the fascicles, being consistent with perifascicular atrophy. Necrosis of the myofibers was not prominent (Fig. 2). Based on these findings, a diagnosis of clinically amyopathic dermatomyositis was made.
Fig. 2 Biopsy specimens from the right masseter muscle. Hematoxylin and eosin staining shows moderate size variation of the myofibers and endomysial and perimysial fibrosis (white arrow). There is atrophy of the myofibers, mainly at the periphery of the fascicles (black arrow), which is consistent with perifascicular atrophy (a). Patchy lymphoplasmacytic infiltration (white arrow) is noted in the stroma (b), which consists of predominantly more CD4-positive cells (c) than CD8-positive cells (d) in immunohistochemical staining. All figures are at 200-fold magnification
Therapy with gamma-globulin (IVIG, 2.1 g/kg per month) in combination with prednisolone 30 mg/day was initiated, and after the first cycle the facial edema had resolved completely. However, when the dose of prednisolone was decreased to 15 mg/day, she made an earlier visit to the clinic with a relapse of the facial edema within six days. By the fourth cycle of IVIG, sustained remission could not be achieved. A course of rituximab (1.0 g twice, a week apart) in combination with methylprednisolone 40 mg/day was started. In the sixth week of rituximab therapy, when glucocorticoid dose was decreased to methylprednisolone 32 mg/day, she presented to the emergency room with altered mentality that began one day prior. On presentation, there was a fever of 38.7 °C, and the patient began mechanical ventilation immediately for hypoxemic respiratory failure. On chest X-ray, there was diffuse consolidation in both lung fields (Fig. 3b). On high-resolution CT, there was diffuse consolidation in the dependent portion of the lungs and diffuse ground glass opacity with relative sparing of the base of the lungs (Fig. 3c, d). The next day, the patient underwent bronchoscopy with bronchoalveolar lavage. The total cell count was 12 × 106 cells in 9 mL of fluid. Differential data of each cell type was as follows: macrophage 8 %, neutrophil 83 %, and lymphocyte 9 %. There was no bacteria isolated from the respiratory specimen, and a polymerase chain reaction (PCR) test for respiratory viruses including adenovirus, influenza virus, parainfluenza virus, and respiratory syncytial virus was negative. Pneumocystis jirovecii PCR and Gomori methenamine silver (GMS) staining were positive, and the patient began treatment with trimethoprim-sulfamethoxazole and glucocorticoids; but her hypoxemic respiratory failure progressed, and veno-venous extracorporeal (ECMO) membrane oxygenation was begun three days later. Given the lack of response to antibiotics therapy, glucocorticoid pulse and IV cyclosporine was started in consideration of rapidly progressive interstitial lung disease (RP-ILD). Over the next three weeks, despite the addition of polymyxin B-immobilized fiber column direct hemoperfusion (PMX-DHP)[11], there was no improvement in her hypoxemic respiratory failure, and according to the family’s will, the ECMO was weaned. On that day, she expired from respiratory failure.
Fig. 3 Chest radiographic images before and at the presentation of acute respiratory failure. Chest postero-anterior radiography taken about one month after initiating rituximab therapy shows no clear haziness or infiltration in both lung fields (a). At the presentation of acute respiratory failure with altered mentality (in the sixth week after starting rituximab) there was diffuse bilateral infiltration in both lung fields with relative sparing of both lower lung fields (b). Axial high-resolution computed tomography images show diffuse ground glass opacity in both upper lungs with consolidation in dependent areas (c); The lung base is relatively spared (d)
Discussion and Conclusions
This case, which posed significant diagnostic and therapeutic challenges, leaves important lessons for practice and research. First, isolated localized edema may be the initial manifestation of CADM. Such a case is considered very rare; we could find only one case reported in sufficient detail for us to verify the absence of muscle disease and other cutaneous manifestations, the prognosis of which was not known[12]. Second, although the patient presented initially with mild glucocorticoid-responsive facial edema, her course showed increasing extent of subcutaneous edema, decreasing response to immunomodulating therapy, and acute and severe involvement of the lungs leading to death. This suggests the prognosis cannot be predicted by the initially mild clinical manifestation alone.
Severe respiratory complications in idiopathic inflammatory myopathies such as DM pose considerable challenges to treatment, and the prognosis is poor[13, 14]. Differential diagnoses include cardiac complications, respiratory muscle weakness, drug hypersensitivity, RP-ILD, and severe and opportunistic infections[15, 16]. In many cases, it is difficult to arrive at a specific diagnosis, and there is a therapeutic dilemma of treating a severe autoimmune inflammation and a difficult-to-treat infection at the same time. Also in this case, there are a couple of explanations for the acute respiratory disease. First, the possibility of Pneumocystis pneumonia (PCP) should be considered. Prolonged glucocorticoid therapy is one of the risk factors for PCP in patients undergoing immunomodulating therapy for systemic autoimmune rheumatic diseases, and the patient was not receiving prophylaxis for it because of thrombocytopenia (< 50,000/mm3). Radiographic findings of acutely developed consolidation and ground glass opacity with relative sparing of the lung base is suggestive of PCP, and PCR and GMS staining were positive. In addition, even with appropriate treatment, mortality in fulminant PCP in non-HIV immunocompromised patients is high; in a recent study, the mortality rate in idiopathic inflammatory myopathy (including CADM) patients admitted to ICUs was 79.4 %, and PCP comprised approximately 20 % of the admissions[13]. Second, we believe the possibility of RP-ILD should be considered. From the early 2000s, associations between CADM and RP-ILD with poor prognosis were reported in Northeast Asia, including Korea, with mortality reaching approximately 50 %[17–19]. Later studies identified an association between anti-melanoma differentiation-associated protein 5 (MDA5) antibody and RP-ILD[20] [21], both of which are more common in CADM than in DM[22], and in Asians compared with Caucasians[21]. Recent studies report initial combination immunosuppressive therapies improved survival in RP-ILD in CADM[23], and that in the case of refractories a rescue therapy with tofacitinib may improve the outcome[24, 25]. Although we could not evaluate the presence of anti-MDA5 Ab in this case, which is a limitation of this study, rapidly progressive ILD was a possibility in the differential diagnosis of acute respiratory failure which did not respond to antibiotic therapy. Third, rituximab-induced lung disease could be considered. The patient developed acute respiratory symptoms five weeks and one day after the last rituximab infusion. This was in the period when late-onset respiratory illness may develop after rituximab infusion. However, late-onset rituximab-induced respiratory illness is less frequent than delayed-onset illness, shows a chronic course over weeks or months, and responds well to glucocorticoid therapy[26].
In conclusion, this case showed that CADM can initially manifest as a localized subcutaneous edema as the sole cutaneous manifestation but follow a progressive, refractory, and fatal course with major organ involvement, especially involving the lungs. A specific auto-antibody pattern may better predict the prognosis. Identification of the specific antibody profile and prompt initiation of therapy with proven efficacy may improve the outcome.
Authors’ contributions.
DHL analyzed clinical data and prepared the manuscript. YMK performed pathologic examination of the muscle biopsy samples and wrote the pathologic results. JHR performed the radiologic examination and muscle biopsy and contributed to writing. JHL, CSP, and SHK participated in critical care of the patient and contributed to writing. SL planned the study and performed analysis of data and literature. All authors read and approved the final manuscript.
Publisher’s Note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
Acknowledgements
Not applicable.
Authors' contributions
DHL analyzed clinical data and prepared the manuscript. YMK performed pathologic examination of the muscle biopsy samples and wrote the pathologic results. JHR performed the radiologic examination and muscle biopsy and contributed to writing. JHL, CSP, and SHK participated in critical care of the patient and contributed to writing. SL planned the study and performed analysis of data and literature. All authors read and approved the final manuscript.
Funding
Not applicable.
Availability of data and materials
Not applicable.
Ethics approval and consent to participate
This study was approved by the institutional review board of Haeundae Paik hospital (IRB file number: HPIRB 2019-08-016-001).
Consent for publication
Written informed consent was obtained from the patient, including the use of photographs of the face.
Competing interests
The authors declare that they have no competing interests. | HUMAN IMMUNOGLOBULIN G, METHYLPREDNISOLONE, PREDNISONE, RITUXIMAB | DrugsGivenReaction | CC BY | 33509162 | 18,862,926 | 2021-01-28 |
Give an alphabetized list of all active substances of drugs taken by the patient who experienced 'Mental status changes'. | Clinically amyopathic dermatomyositis presenting with isolated facial edema complicated by acute respiratory failure: a case report.
BACKGROUND
In clinically amyopathic dermatomyositis, the hallmark cutaneous manifestations are the key to diagnosis. We report a case of clinically amyopathic dermatomyositis which presented with facial edema as the sole cutaneous manifestation and was later complicated by acute respiratory failure leading to death.
METHODS
A 58-year-old woman presented with edema of the face that had developed approximately one year ago. There was no weakness in the extremities, and the serum creatine kinase level was within normal range. On MRI, there was diffuse edematous change in the bilateral masticator and extra-ocular muscles, accompanied by subcutaneous fat infiltration in the face. A shared decision was made to defer muscle biopsy in the facial muscles. The facial swelling almost resolved with medium-dose glucocorticoid therapy but relapsed in days at glucocorticoid doses lower than 15 mg/day. Combination therapy with either azathioprine, mycophenolate, or methotrexate was not successful in maintaining clinical remission, and the swelling became more severe after relapses. A US-guided core-needle biopsy was subsequently performed in the right masseter muscle. On pathologic examination, there was a patchy CD4 + T cell-dominant lymphoplasmacytic infiltration in the stroma, necrosis of the myofibrils and prominent perifascicular atrophy. Based on those findings, a diagnosis of clinically amyopathic dermatomyositis was made. Therapy with gamma-globulin was not effective in maintaining remission. In the sixth week after starting rituximab, she presented to emergency room with altered mental state from acute respiratory failure. Despite treatment with antibiotics, glucocorticoid pulse, cyclosporin, and polymyxin B-immobilized fiber column direct hemoperfusion, she died three weeks later from persistent hypoxemic respiratory failure.
CONCLUSIONS
This case showed the full spectrum and severity of internal organ involvement of dermatomyositis, although the patient presented exclusively with subcutaneous edema limited to the head. The prognosis may be more closely associated with a specific auto-antibody profile than the benign-looking initial clinical manifestation. Close follow-up of lung involvement with prophylactic treatment for Pneumocystis pneumonia and prompt implementation of emerging therapeutic regimens may improve the outcome.
Background
Even before the classification of dermatomyositis (DM) was defined by Bohan and Peter in 1975, it was well known that there was a subgroup of patients who did not have muscle disease, regarded as amyopathic dermatomyositis (ADM)[1]. Studies have shown that there is evidence of subclinical muscle disease in MRI imaging and muscle biopsy in ADM leading to the concept of clinically amyopathic dermatomyositis (CADM), which is defined as absence of clinical muscle disease on physical examination and muscle enzyme analysis for at least six months[2]. In CADM, which represents about 11–20 % of dermatomyositis (DM)[3, 4], the hallmark cutaneous manifestations such as Heliotrope rash, Gottron’s papules, and Gottron’s sign are the key to diagnosis.
There has been a report that suggested that subcutaneous edema is a cutaneous manifestation of DM because it can be the only skin lesion at presentation[5]. In the case series, edematous DM comprised 6 % (5/86) of a DM cohort. In the muscle biopsies of the five cases of edematous DM, there were frequent microinfarctions, which were considered to be induced by vasculitis producing micro-ischemia. In the reported five cases and review of 19 reported cases, there were six cases (3/5 and 3/19, respectively) in which subcutaneous edema was the sole cutaneous manifestation, but all had clinical muscle disease, suggesting that CADM presenting exclusively with subcutaneous edema is very rare. In this study, we report a case of CADM which presented with facial edema as the sole cutaneous manifestation and was later complicated by acute respiratory failure leading to mortality.
Case presentation
A 58-year-old woman presented with edema of the face that had developed approximately one year prior. It was not painful nor pruritic, but she felt it was more prominent on the left side. Courses of antibiotic therapy for a presumed diagnosis of cellulitis had not been effective, but glucocorticoids greatly improved the swelling, which relapsed rapidly with tapering. One week prior, as another course of glucocorticoids prescribed for a diagnosis of angioedema was tapered out, her facial edema relapsed, accompanied by tiny, pruritic vesicular lesions on the chin. Although she was evaluated in neurology and dental clinics, no specific diagnosis was made. She reported ‘dryness’ and ‘itchiness’ of the eyes, but not in the oral cavity.
On evaluation, there was bilateral swelling of the malar and temporal area of the face, involving the periorbital area and eyelid in the left side. On the chin, there was eczematoid vesicular eruption (Fig. 1a). There was no abnormal finding on the examination of the chest and abdomen. There was no edema or rash in the trunk or extremities. Neck flexion was preserved, and the power of the extremities’ motor function was evaluated as five on a scale of zero to five. On ophthalmologic examination, there was swelling of the left upper eyelid, and the anterior chamber was clear and deep in both eyes. Five-minute Schirmer test result was 6 mm in the right eye and 8 mm in the left eye (reference value < 5 mm for dry eye disease, but known to have low sensitivity in mild or moderate cases)[6]. Ocular staining score was 1 and 2 in the right and left eye, respectively (reference value ≥ 5 for classification of primary Sjögren’s syndrome)[7].
Fig. 1 Isolated facial edema and subclinical facial muscle involvement. At initial presentation there was bilateral swelling of the face and of the left eyelid, accompanied by eczematoid eruption on the chin (a). After approximately two weeks of medium-dose glucocorticoid therapy the edema and the lesions were completely resolved (b). However, combination therapy with either azathioprine, mycophenolate, or methotrexate was not successful in maintaining remission at a prednisolone dose lower than 15 mg per day. At the last relapse, there was marked aggravation of facial and eyelid edema (c). Gadolinium-enhanced MRI scan of the head shows diffuse edematous change with enhancement of bilateral masticator muscles (d, masseter muscle [yellow arrow] and lateral pterygoid muscle [black arrow]). There was also swelling of bilateral extra-ocular muscles and edematous change with fat infiltration in the subcutaneous tissues of the anterior scalp, periorbital area, buccal space, and anterior cervical fascia (not shown)
On the initial laboratory evaluation, there were no abnormalities, and the serum creatine phosphokinase (CPK) level was within normal range (Table 1). On serologic evaluation, antinuclear antibody was positive up to 1:160 in titer in homogeneous pattern, but anti-dsDNA Ab and anti-histone Ab was negative. Anti-SSA (> 240 U/mL) and anti-SSB (18 U/mL) antibodies were positive (fluorescent enzyme immunoassay, reference value < 7 U/mL for both); anti-RNP and anti-Smith Ab, negative. Anti-Jo1 antibody and anti-SRP antibody were negative. Anti-neutrophil cytoplasmic antibody was negative and IgG4 level was within normal range: 102 mg/dL (reference 30 ~ 201 mg/dL).
Table 1 Laboratory data
Variable Reference range At initial presentation At the second admission
WBC 4.0 ~ 10.0 × 109/L 5.2 2.84
RBC 4.2 ~ 5.4 × 1012/L 4.23 4.38
Hgb 12.0 ~ 16.0 g/dL 12.4 13.7
Platelet 140 ~ 440 × 109/L 230 166
Differential Count
Neutrophil 40 ~ 80 % 57.8 66.8
Lymphocyte 15 ~ 50 % 30.2 20.8
Monocyte 2 ~ 11 % 7.9 9.2
Eosinophil 0 ~ 7 % 3.5 2.8
Basophil 0 ~ 1 % 0.6 0.4
ESR ~ 120 mm 14 21
Total Protein 6.0 ~ 8.0 g/dl 7.4 7.1
Albumin 3.5 ~ 5.2 g/dl 4.3 4.1
Total Bilirubin ~ 1.2 mg/dl 0.64 1.01
AST 7 ~ 38 U/L 36 50
ALT 4 ~ 43 U/L 32 69
ALP 36 ~ 104 U/L 79 58
Glucose 70 ~ 110 mg/dl 84 109
Total Cholesterol ~ 200 mg/dl 171 204
BUN 6.0 ~ 20.0 mg/dl 16 18.6
Creatinine 0.6 ~ 1.2 mg/dl 0.79 0.82
Direct Bilirubin ~ 0.3 mg/dl 0.19 0.24
LDH ~ 250 IU/L 269 424
CPK 50 ~ 200 U/L 182 317
Uric acid 3.0 ~ 5.5 mg/dl 3.5 3.4
CRP ~ 0.30 mg/dL 0.05 0.68
WBC white blood cell, RBC red blood cell, ESR erythrocyte sedimentation rate, AST aspartate aminotransferase, ALT alanine aminotransferase, ALP alkaline phosphatase, BUN blood urea nitrogen, LDH lactase dehydrogenase, CPK creatine phosphokinase, CRP C-reactive protein
On MRI, there was a diffuse edematous change in the bilateral masticator and extra-ocular muscles, accompanied by subcutaneous fat infiltration in the buccal and periorbital spaces. There was inhomogeneous enhancement of bilateral parotid glands. On PET-CT scan there was diffuse F-18-FDG uptake in the periorbital, frontalis, temporalis, and masseter muscles and the buccal and submandibular spaces without any increased uptake in the extremities or internal organs.
The Head and Neck Surgery and Radiology departments opined that a biopsy of the muscles would entail risk of complications such as bleeding and injury to the muscles. After a discussion with the patient regarding undergoing a muscle biopsy, a presumptive clinical diagnosis of an overlap syndrome of Sjogren’s syndrome with myositis was made and treatment with a medium-dose glucocorticoid (prednisolone 30 mg/day) begun; based on reports of orbital involvement, a good response to therapy, and benign prognosis in myositis associated with Sjogren’s syndrome[8–10]. On 16th day of treatment, the facial swelling was assessed as having completely resolved (Fig. 1b); however, the facial edema relapsed during subsequent days when glucocorticoid doses were lowered to less than 15 mg/day. Combination therapy with azathioprine, mycophenolate, or methotrexate for eight months was not effective in maintaining remission at acceptable doses of glucocorticoid, and the swelling aggravated considerably with the final relapse.
The patient finally agreed to further evaluation and was admitted to the hospital. On examination, there was aggravation of the facial edema (Fig. 1c). There was swelling of the right ankle, without tenderness. Neck flexion was preserved and motor power of extremities was assessed as five on a scale of zero to five. On laboratory evaluation, there was mild elevation of liver transaminases and CPK (Table 1). Serum aldolase was 7.9 U/L (reference < 7.6 U/L). On MRI of the head, there was aggravation of the inflammation (Fig. 1d). On ultrasonography of the right ankle, there was subcutaneous edema without evidence of synovitis. A series of evaluations to screen for malignancy including tumor makers (CA19-9, CEA, and CA125), esophagogastroduodenoscopy, colonoscopy, and mammography did not reveal abnormal findings.
A US-guided core-needle biopsy with an 18-gauge needle was performed in the right masseter muscle. Two pieces of tiny muscle tissue, measuring up to 0.5 × 0.1 cm, were obtained. On pathologic examination, there was moderate size variation of the myofibers, and endomysial and perimysial fibrosis. There was patchy CD4 + T cell-dominant lymphoplasmacytic infiltration in the stroma and atrophy of the myofibers, mainly at the periphery of the fascicles, being consistent with perifascicular atrophy. Necrosis of the myofibers was not prominent (Fig. 2). Based on these findings, a diagnosis of clinically amyopathic dermatomyositis was made.
Fig. 2 Biopsy specimens from the right masseter muscle. Hematoxylin and eosin staining shows moderate size variation of the myofibers and endomysial and perimysial fibrosis (white arrow). There is atrophy of the myofibers, mainly at the periphery of the fascicles (black arrow), which is consistent with perifascicular atrophy (a). Patchy lymphoplasmacytic infiltration (white arrow) is noted in the stroma (b), which consists of predominantly more CD4-positive cells (c) than CD8-positive cells (d) in immunohistochemical staining. All figures are at 200-fold magnification
Therapy with gamma-globulin (IVIG, 2.1 g/kg per month) in combination with prednisolone 30 mg/day was initiated, and after the first cycle the facial edema had resolved completely. However, when the dose of prednisolone was decreased to 15 mg/day, she made an earlier visit to the clinic with a relapse of the facial edema within six days. By the fourth cycle of IVIG, sustained remission could not be achieved. A course of rituximab (1.0 g twice, a week apart) in combination with methylprednisolone 40 mg/day was started. In the sixth week of rituximab therapy, when glucocorticoid dose was decreased to methylprednisolone 32 mg/day, she presented to the emergency room with altered mentality that began one day prior. On presentation, there was a fever of 38.7 °C, and the patient began mechanical ventilation immediately for hypoxemic respiratory failure. On chest X-ray, there was diffuse consolidation in both lung fields (Fig. 3b). On high-resolution CT, there was diffuse consolidation in the dependent portion of the lungs and diffuse ground glass opacity with relative sparing of the base of the lungs (Fig. 3c, d). The next day, the patient underwent bronchoscopy with bronchoalveolar lavage. The total cell count was 12 × 106 cells in 9 mL of fluid. Differential data of each cell type was as follows: macrophage 8 %, neutrophil 83 %, and lymphocyte 9 %. There was no bacteria isolated from the respiratory specimen, and a polymerase chain reaction (PCR) test for respiratory viruses including adenovirus, influenza virus, parainfluenza virus, and respiratory syncytial virus was negative. Pneumocystis jirovecii PCR and Gomori methenamine silver (GMS) staining were positive, and the patient began treatment with trimethoprim-sulfamethoxazole and glucocorticoids; but her hypoxemic respiratory failure progressed, and veno-venous extracorporeal (ECMO) membrane oxygenation was begun three days later. Given the lack of response to antibiotics therapy, glucocorticoid pulse and IV cyclosporine was started in consideration of rapidly progressive interstitial lung disease (RP-ILD). Over the next three weeks, despite the addition of polymyxin B-immobilized fiber column direct hemoperfusion (PMX-DHP)[11], there was no improvement in her hypoxemic respiratory failure, and according to the family’s will, the ECMO was weaned. On that day, she expired from respiratory failure.
Fig. 3 Chest radiographic images before and at the presentation of acute respiratory failure. Chest postero-anterior radiography taken about one month after initiating rituximab therapy shows no clear haziness or infiltration in both lung fields (a). At the presentation of acute respiratory failure with altered mentality (in the sixth week after starting rituximab) there was diffuse bilateral infiltration in both lung fields with relative sparing of both lower lung fields (b). Axial high-resolution computed tomography images show diffuse ground glass opacity in both upper lungs with consolidation in dependent areas (c); The lung base is relatively spared (d)
Discussion and Conclusions
This case, which posed significant diagnostic and therapeutic challenges, leaves important lessons for practice and research. First, isolated localized edema may be the initial manifestation of CADM. Such a case is considered very rare; we could find only one case reported in sufficient detail for us to verify the absence of muscle disease and other cutaneous manifestations, the prognosis of which was not known[12]. Second, although the patient presented initially with mild glucocorticoid-responsive facial edema, her course showed increasing extent of subcutaneous edema, decreasing response to immunomodulating therapy, and acute and severe involvement of the lungs leading to death. This suggests the prognosis cannot be predicted by the initially mild clinical manifestation alone.
Severe respiratory complications in idiopathic inflammatory myopathies such as DM pose considerable challenges to treatment, and the prognosis is poor[13, 14]. Differential diagnoses include cardiac complications, respiratory muscle weakness, drug hypersensitivity, RP-ILD, and severe and opportunistic infections[15, 16]. In many cases, it is difficult to arrive at a specific diagnosis, and there is a therapeutic dilemma of treating a severe autoimmune inflammation and a difficult-to-treat infection at the same time. Also in this case, there are a couple of explanations for the acute respiratory disease. First, the possibility of Pneumocystis pneumonia (PCP) should be considered. Prolonged glucocorticoid therapy is one of the risk factors for PCP in patients undergoing immunomodulating therapy for systemic autoimmune rheumatic diseases, and the patient was not receiving prophylaxis for it because of thrombocytopenia (< 50,000/mm3). Radiographic findings of acutely developed consolidation and ground glass opacity with relative sparing of the lung base is suggestive of PCP, and PCR and GMS staining were positive. In addition, even with appropriate treatment, mortality in fulminant PCP in non-HIV immunocompromised patients is high; in a recent study, the mortality rate in idiopathic inflammatory myopathy (including CADM) patients admitted to ICUs was 79.4 %, and PCP comprised approximately 20 % of the admissions[13]. Second, we believe the possibility of RP-ILD should be considered. From the early 2000s, associations between CADM and RP-ILD with poor prognosis were reported in Northeast Asia, including Korea, with mortality reaching approximately 50 %[17–19]. Later studies identified an association between anti-melanoma differentiation-associated protein 5 (MDA5) antibody and RP-ILD[20] [21], both of which are more common in CADM than in DM[22], and in Asians compared with Caucasians[21]. Recent studies report initial combination immunosuppressive therapies improved survival in RP-ILD in CADM[23], and that in the case of refractories a rescue therapy with tofacitinib may improve the outcome[24, 25]. Although we could not evaluate the presence of anti-MDA5 Ab in this case, which is a limitation of this study, rapidly progressive ILD was a possibility in the differential diagnosis of acute respiratory failure which did not respond to antibiotic therapy. Third, rituximab-induced lung disease could be considered. The patient developed acute respiratory symptoms five weeks and one day after the last rituximab infusion. This was in the period when late-onset respiratory illness may develop after rituximab infusion. However, late-onset rituximab-induced respiratory illness is less frequent than delayed-onset illness, shows a chronic course over weeks or months, and responds well to glucocorticoid therapy[26].
In conclusion, this case showed that CADM can initially manifest as a localized subcutaneous edema as the sole cutaneous manifestation but follow a progressive, refractory, and fatal course with major organ involvement, especially involving the lungs. A specific auto-antibody pattern may better predict the prognosis. Identification of the specific antibody profile and prompt initiation of therapy with proven efficacy may improve the outcome.
Authors’ contributions.
DHL analyzed clinical data and prepared the manuscript. YMK performed pathologic examination of the muscle biopsy samples and wrote the pathologic results. JHR performed the radiologic examination and muscle biopsy and contributed to writing. JHL, CSP, and SHK participated in critical care of the patient and contributed to writing. SL planned the study and performed analysis of data and literature. All authors read and approved the final manuscript.
Publisher’s Note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
Acknowledgements
Not applicable.
Authors' contributions
DHL analyzed clinical data and prepared the manuscript. YMK performed pathologic examination of the muscle biopsy samples and wrote the pathologic results. JHR performed the radiologic examination and muscle biopsy and contributed to writing. JHL, CSP, and SHK participated in critical care of the patient and contributed to writing. SL planned the study and performed analysis of data and literature. All authors read and approved the final manuscript.
Funding
Not applicable.
Availability of data and materials
Not applicable.
Ethics approval and consent to participate
This study was approved by the institutional review board of Haeundae Paik hospital (IRB file number: HPIRB 2019-08-016-001).
Consent for publication
Written informed consent was obtained from the patient, including the use of photographs of the face.
Competing interests
The authors declare that they have no competing interests. | HUMAN IMMUNOGLOBULIN G, METHYLPREDNISOLONE, PREDNISONE, RITUXIMAB | DrugsGivenReaction | CC BY | 33509162 | 18,862,926 | 2021-01-28 |
Give an alphabetized list of all active substances of drugs taken by the patient who experienced 'Pneumocystis jirovecii pneumonia'. | Clinically amyopathic dermatomyositis presenting with isolated facial edema complicated by acute respiratory failure: a case report.
BACKGROUND
In clinically amyopathic dermatomyositis, the hallmark cutaneous manifestations are the key to diagnosis. We report a case of clinically amyopathic dermatomyositis which presented with facial edema as the sole cutaneous manifestation and was later complicated by acute respiratory failure leading to death.
METHODS
A 58-year-old woman presented with edema of the face that had developed approximately one year ago. There was no weakness in the extremities, and the serum creatine kinase level was within normal range. On MRI, there was diffuse edematous change in the bilateral masticator and extra-ocular muscles, accompanied by subcutaneous fat infiltration in the face. A shared decision was made to defer muscle biopsy in the facial muscles. The facial swelling almost resolved with medium-dose glucocorticoid therapy but relapsed in days at glucocorticoid doses lower than 15 mg/day. Combination therapy with either azathioprine, mycophenolate, or methotrexate was not successful in maintaining clinical remission, and the swelling became more severe after relapses. A US-guided core-needle biopsy was subsequently performed in the right masseter muscle. On pathologic examination, there was a patchy CD4 + T cell-dominant lymphoplasmacytic infiltration in the stroma, necrosis of the myofibrils and prominent perifascicular atrophy. Based on those findings, a diagnosis of clinically amyopathic dermatomyositis was made. Therapy with gamma-globulin was not effective in maintaining remission. In the sixth week after starting rituximab, she presented to emergency room with altered mental state from acute respiratory failure. Despite treatment with antibiotics, glucocorticoid pulse, cyclosporin, and polymyxin B-immobilized fiber column direct hemoperfusion, she died three weeks later from persistent hypoxemic respiratory failure.
CONCLUSIONS
This case showed the full spectrum and severity of internal organ involvement of dermatomyositis, although the patient presented exclusively with subcutaneous edema limited to the head. The prognosis may be more closely associated with a specific auto-antibody profile than the benign-looking initial clinical manifestation. Close follow-up of lung involvement with prophylactic treatment for Pneumocystis pneumonia and prompt implementation of emerging therapeutic regimens may improve the outcome.
Background
Even before the classification of dermatomyositis (DM) was defined by Bohan and Peter in 1975, it was well known that there was a subgroup of patients who did not have muscle disease, regarded as amyopathic dermatomyositis (ADM)[1]. Studies have shown that there is evidence of subclinical muscle disease in MRI imaging and muscle biopsy in ADM leading to the concept of clinically amyopathic dermatomyositis (CADM), which is defined as absence of clinical muscle disease on physical examination and muscle enzyme analysis for at least six months[2]. In CADM, which represents about 11–20 % of dermatomyositis (DM)[3, 4], the hallmark cutaneous manifestations such as Heliotrope rash, Gottron’s papules, and Gottron’s sign are the key to diagnosis.
There has been a report that suggested that subcutaneous edema is a cutaneous manifestation of DM because it can be the only skin lesion at presentation[5]. In the case series, edematous DM comprised 6 % (5/86) of a DM cohort. In the muscle biopsies of the five cases of edematous DM, there were frequent microinfarctions, which were considered to be induced by vasculitis producing micro-ischemia. In the reported five cases and review of 19 reported cases, there were six cases (3/5 and 3/19, respectively) in which subcutaneous edema was the sole cutaneous manifestation, but all had clinical muscle disease, suggesting that CADM presenting exclusively with subcutaneous edema is very rare. In this study, we report a case of CADM which presented with facial edema as the sole cutaneous manifestation and was later complicated by acute respiratory failure leading to mortality.
Case presentation
A 58-year-old woman presented with edema of the face that had developed approximately one year prior. It was not painful nor pruritic, but she felt it was more prominent on the left side. Courses of antibiotic therapy for a presumed diagnosis of cellulitis had not been effective, but glucocorticoids greatly improved the swelling, which relapsed rapidly with tapering. One week prior, as another course of glucocorticoids prescribed for a diagnosis of angioedema was tapered out, her facial edema relapsed, accompanied by tiny, pruritic vesicular lesions on the chin. Although she was evaluated in neurology and dental clinics, no specific diagnosis was made. She reported ‘dryness’ and ‘itchiness’ of the eyes, but not in the oral cavity.
On evaluation, there was bilateral swelling of the malar and temporal area of the face, involving the periorbital area and eyelid in the left side. On the chin, there was eczematoid vesicular eruption (Fig. 1a). There was no abnormal finding on the examination of the chest and abdomen. There was no edema or rash in the trunk or extremities. Neck flexion was preserved, and the power of the extremities’ motor function was evaluated as five on a scale of zero to five. On ophthalmologic examination, there was swelling of the left upper eyelid, and the anterior chamber was clear and deep in both eyes. Five-minute Schirmer test result was 6 mm in the right eye and 8 mm in the left eye (reference value < 5 mm for dry eye disease, but known to have low sensitivity in mild or moderate cases)[6]. Ocular staining score was 1 and 2 in the right and left eye, respectively (reference value ≥ 5 for classification of primary Sjögren’s syndrome)[7].
Fig. 1 Isolated facial edema and subclinical facial muscle involvement. At initial presentation there was bilateral swelling of the face and of the left eyelid, accompanied by eczematoid eruption on the chin (a). After approximately two weeks of medium-dose glucocorticoid therapy the edema and the lesions were completely resolved (b). However, combination therapy with either azathioprine, mycophenolate, or methotrexate was not successful in maintaining remission at a prednisolone dose lower than 15 mg per day. At the last relapse, there was marked aggravation of facial and eyelid edema (c). Gadolinium-enhanced MRI scan of the head shows diffuse edematous change with enhancement of bilateral masticator muscles (d, masseter muscle [yellow arrow] and lateral pterygoid muscle [black arrow]). There was also swelling of bilateral extra-ocular muscles and edematous change with fat infiltration in the subcutaneous tissues of the anterior scalp, periorbital area, buccal space, and anterior cervical fascia (not shown)
On the initial laboratory evaluation, there were no abnormalities, and the serum creatine phosphokinase (CPK) level was within normal range (Table 1). On serologic evaluation, antinuclear antibody was positive up to 1:160 in titer in homogeneous pattern, but anti-dsDNA Ab and anti-histone Ab was negative. Anti-SSA (> 240 U/mL) and anti-SSB (18 U/mL) antibodies were positive (fluorescent enzyme immunoassay, reference value < 7 U/mL for both); anti-RNP and anti-Smith Ab, negative. Anti-Jo1 antibody and anti-SRP antibody were negative. Anti-neutrophil cytoplasmic antibody was negative and IgG4 level was within normal range: 102 mg/dL (reference 30 ~ 201 mg/dL).
Table 1 Laboratory data
Variable Reference range At initial presentation At the second admission
WBC 4.0 ~ 10.0 × 109/L 5.2 2.84
RBC 4.2 ~ 5.4 × 1012/L 4.23 4.38
Hgb 12.0 ~ 16.0 g/dL 12.4 13.7
Platelet 140 ~ 440 × 109/L 230 166
Differential Count
Neutrophil 40 ~ 80 % 57.8 66.8
Lymphocyte 15 ~ 50 % 30.2 20.8
Monocyte 2 ~ 11 % 7.9 9.2
Eosinophil 0 ~ 7 % 3.5 2.8
Basophil 0 ~ 1 % 0.6 0.4
ESR ~ 120 mm 14 21
Total Protein 6.0 ~ 8.0 g/dl 7.4 7.1
Albumin 3.5 ~ 5.2 g/dl 4.3 4.1
Total Bilirubin ~ 1.2 mg/dl 0.64 1.01
AST 7 ~ 38 U/L 36 50
ALT 4 ~ 43 U/L 32 69
ALP 36 ~ 104 U/L 79 58
Glucose 70 ~ 110 mg/dl 84 109
Total Cholesterol ~ 200 mg/dl 171 204
BUN 6.0 ~ 20.0 mg/dl 16 18.6
Creatinine 0.6 ~ 1.2 mg/dl 0.79 0.82
Direct Bilirubin ~ 0.3 mg/dl 0.19 0.24
LDH ~ 250 IU/L 269 424
CPK 50 ~ 200 U/L 182 317
Uric acid 3.0 ~ 5.5 mg/dl 3.5 3.4
CRP ~ 0.30 mg/dL 0.05 0.68
WBC white blood cell, RBC red blood cell, ESR erythrocyte sedimentation rate, AST aspartate aminotransferase, ALT alanine aminotransferase, ALP alkaline phosphatase, BUN blood urea nitrogen, LDH lactase dehydrogenase, CPK creatine phosphokinase, CRP C-reactive protein
On MRI, there was a diffuse edematous change in the bilateral masticator and extra-ocular muscles, accompanied by subcutaneous fat infiltration in the buccal and periorbital spaces. There was inhomogeneous enhancement of bilateral parotid glands. On PET-CT scan there was diffuse F-18-FDG uptake in the periorbital, frontalis, temporalis, and masseter muscles and the buccal and submandibular spaces without any increased uptake in the extremities or internal organs.
The Head and Neck Surgery and Radiology departments opined that a biopsy of the muscles would entail risk of complications such as bleeding and injury to the muscles. After a discussion with the patient regarding undergoing a muscle biopsy, a presumptive clinical diagnosis of an overlap syndrome of Sjogren’s syndrome with myositis was made and treatment with a medium-dose glucocorticoid (prednisolone 30 mg/day) begun; based on reports of orbital involvement, a good response to therapy, and benign prognosis in myositis associated with Sjogren’s syndrome[8–10]. On 16th day of treatment, the facial swelling was assessed as having completely resolved (Fig. 1b); however, the facial edema relapsed during subsequent days when glucocorticoid doses were lowered to less than 15 mg/day. Combination therapy with azathioprine, mycophenolate, or methotrexate for eight months was not effective in maintaining remission at acceptable doses of glucocorticoid, and the swelling aggravated considerably with the final relapse.
The patient finally agreed to further evaluation and was admitted to the hospital. On examination, there was aggravation of the facial edema (Fig. 1c). There was swelling of the right ankle, without tenderness. Neck flexion was preserved and motor power of extremities was assessed as five on a scale of zero to five. On laboratory evaluation, there was mild elevation of liver transaminases and CPK (Table 1). Serum aldolase was 7.9 U/L (reference < 7.6 U/L). On MRI of the head, there was aggravation of the inflammation (Fig. 1d). On ultrasonography of the right ankle, there was subcutaneous edema without evidence of synovitis. A series of evaluations to screen for malignancy including tumor makers (CA19-9, CEA, and CA125), esophagogastroduodenoscopy, colonoscopy, and mammography did not reveal abnormal findings.
A US-guided core-needle biopsy with an 18-gauge needle was performed in the right masseter muscle. Two pieces of tiny muscle tissue, measuring up to 0.5 × 0.1 cm, were obtained. On pathologic examination, there was moderate size variation of the myofibers, and endomysial and perimysial fibrosis. There was patchy CD4 + T cell-dominant lymphoplasmacytic infiltration in the stroma and atrophy of the myofibers, mainly at the periphery of the fascicles, being consistent with perifascicular atrophy. Necrosis of the myofibers was not prominent (Fig. 2). Based on these findings, a diagnosis of clinically amyopathic dermatomyositis was made.
Fig. 2 Biopsy specimens from the right masseter muscle. Hematoxylin and eosin staining shows moderate size variation of the myofibers and endomysial and perimysial fibrosis (white arrow). There is atrophy of the myofibers, mainly at the periphery of the fascicles (black arrow), which is consistent with perifascicular atrophy (a). Patchy lymphoplasmacytic infiltration (white arrow) is noted in the stroma (b), which consists of predominantly more CD4-positive cells (c) than CD8-positive cells (d) in immunohistochemical staining. All figures are at 200-fold magnification
Therapy with gamma-globulin (IVIG, 2.1 g/kg per month) in combination with prednisolone 30 mg/day was initiated, and after the first cycle the facial edema had resolved completely. However, when the dose of prednisolone was decreased to 15 mg/day, she made an earlier visit to the clinic with a relapse of the facial edema within six days. By the fourth cycle of IVIG, sustained remission could not be achieved. A course of rituximab (1.0 g twice, a week apart) in combination with methylprednisolone 40 mg/day was started. In the sixth week of rituximab therapy, when glucocorticoid dose was decreased to methylprednisolone 32 mg/day, she presented to the emergency room with altered mentality that began one day prior. On presentation, there was a fever of 38.7 °C, and the patient began mechanical ventilation immediately for hypoxemic respiratory failure. On chest X-ray, there was diffuse consolidation in both lung fields (Fig. 3b). On high-resolution CT, there was diffuse consolidation in the dependent portion of the lungs and diffuse ground glass opacity with relative sparing of the base of the lungs (Fig. 3c, d). The next day, the patient underwent bronchoscopy with bronchoalveolar lavage. The total cell count was 12 × 106 cells in 9 mL of fluid. Differential data of each cell type was as follows: macrophage 8 %, neutrophil 83 %, and lymphocyte 9 %. There was no bacteria isolated from the respiratory specimen, and a polymerase chain reaction (PCR) test for respiratory viruses including adenovirus, influenza virus, parainfluenza virus, and respiratory syncytial virus was negative. Pneumocystis jirovecii PCR and Gomori methenamine silver (GMS) staining were positive, and the patient began treatment with trimethoprim-sulfamethoxazole and glucocorticoids; but her hypoxemic respiratory failure progressed, and veno-venous extracorporeal (ECMO) membrane oxygenation was begun three days later. Given the lack of response to antibiotics therapy, glucocorticoid pulse and IV cyclosporine was started in consideration of rapidly progressive interstitial lung disease (RP-ILD). Over the next three weeks, despite the addition of polymyxin B-immobilized fiber column direct hemoperfusion (PMX-DHP)[11], there was no improvement in her hypoxemic respiratory failure, and according to the family’s will, the ECMO was weaned. On that day, she expired from respiratory failure.
Fig. 3 Chest radiographic images before and at the presentation of acute respiratory failure. Chest postero-anterior radiography taken about one month after initiating rituximab therapy shows no clear haziness or infiltration in both lung fields (a). At the presentation of acute respiratory failure with altered mentality (in the sixth week after starting rituximab) there was diffuse bilateral infiltration in both lung fields with relative sparing of both lower lung fields (b). Axial high-resolution computed tomography images show diffuse ground glass opacity in both upper lungs with consolidation in dependent areas (c); The lung base is relatively spared (d)
Discussion and Conclusions
This case, which posed significant diagnostic and therapeutic challenges, leaves important lessons for practice and research. First, isolated localized edema may be the initial manifestation of CADM. Such a case is considered very rare; we could find only one case reported in sufficient detail for us to verify the absence of muscle disease and other cutaneous manifestations, the prognosis of which was not known[12]. Second, although the patient presented initially with mild glucocorticoid-responsive facial edema, her course showed increasing extent of subcutaneous edema, decreasing response to immunomodulating therapy, and acute and severe involvement of the lungs leading to death. This suggests the prognosis cannot be predicted by the initially mild clinical manifestation alone.
Severe respiratory complications in idiopathic inflammatory myopathies such as DM pose considerable challenges to treatment, and the prognosis is poor[13, 14]. Differential diagnoses include cardiac complications, respiratory muscle weakness, drug hypersensitivity, RP-ILD, and severe and opportunistic infections[15, 16]. In many cases, it is difficult to arrive at a specific diagnosis, and there is a therapeutic dilemma of treating a severe autoimmune inflammation and a difficult-to-treat infection at the same time. Also in this case, there are a couple of explanations for the acute respiratory disease. First, the possibility of Pneumocystis pneumonia (PCP) should be considered. Prolonged glucocorticoid therapy is one of the risk factors for PCP in patients undergoing immunomodulating therapy for systemic autoimmune rheumatic diseases, and the patient was not receiving prophylaxis for it because of thrombocytopenia (< 50,000/mm3). Radiographic findings of acutely developed consolidation and ground glass opacity with relative sparing of the lung base is suggestive of PCP, and PCR and GMS staining were positive. In addition, even with appropriate treatment, mortality in fulminant PCP in non-HIV immunocompromised patients is high; in a recent study, the mortality rate in idiopathic inflammatory myopathy (including CADM) patients admitted to ICUs was 79.4 %, and PCP comprised approximately 20 % of the admissions[13]. Second, we believe the possibility of RP-ILD should be considered. From the early 2000s, associations between CADM and RP-ILD with poor prognosis were reported in Northeast Asia, including Korea, with mortality reaching approximately 50 %[17–19]. Later studies identified an association between anti-melanoma differentiation-associated protein 5 (MDA5) antibody and RP-ILD[20] [21], both of which are more common in CADM than in DM[22], and in Asians compared with Caucasians[21]. Recent studies report initial combination immunosuppressive therapies improved survival in RP-ILD in CADM[23], and that in the case of refractories a rescue therapy with tofacitinib may improve the outcome[24, 25]. Although we could not evaluate the presence of anti-MDA5 Ab in this case, which is a limitation of this study, rapidly progressive ILD was a possibility in the differential diagnosis of acute respiratory failure which did not respond to antibiotic therapy. Third, rituximab-induced lung disease could be considered. The patient developed acute respiratory symptoms five weeks and one day after the last rituximab infusion. This was in the period when late-onset respiratory illness may develop after rituximab infusion. However, late-onset rituximab-induced respiratory illness is less frequent than delayed-onset illness, shows a chronic course over weeks or months, and responds well to glucocorticoid therapy[26].
In conclusion, this case showed that CADM can initially manifest as a localized subcutaneous edema as the sole cutaneous manifestation but follow a progressive, refractory, and fatal course with major organ involvement, especially involving the lungs. A specific auto-antibody pattern may better predict the prognosis. Identification of the specific antibody profile and prompt initiation of therapy with proven efficacy may improve the outcome.
Authors’ contributions.
DHL analyzed clinical data and prepared the manuscript. YMK performed pathologic examination of the muscle biopsy samples and wrote the pathologic results. JHR performed the radiologic examination and muscle biopsy and contributed to writing. JHL, CSP, and SHK participated in critical care of the patient and contributed to writing. SL planned the study and performed analysis of data and literature. All authors read and approved the final manuscript.
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Acknowledgements
Not applicable.
Authors' contributions
DHL analyzed clinical data and prepared the manuscript. YMK performed pathologic examination of the muscle biopsy samples and wrote the pathologic results. JHR performed the radiologic examination and muscle biopsy and contributed to writing. JHL, CSP, and SHK participated in critical care of the patient and contributed to writing. SL planned the study and performed analysis of data and literature. All authors read and approved the final manuscript.
Funding
Not applicable.
Availability of data and materials
Not applicable.
Ethics approval and consent to participate
This study was approved by the institutional review board of Haeundae Paik hospital (IRB file number: HPIRB 2019-08-016-001).
Consent for publication
Written informed consent was obtained from the patient, including the use of photographs of the face.
Competing interests
The authors declare that they have no competing interests. | AZATHIOPRINE, METHOTREXATE, METHYLPREDNISOLONE, MYCOPHENOLATE MOFETIL, PREDNISOLONE, RITUXIMAB | DrugsGivenReaction | CC BY | 33509162 | 19,217,583 | 2021-01-28 |
Give an alphabetized list of all active substances of drugs taken by the patient who experienced 'Rebound effect'. | Clinically amyopathic dermatomyositis presenting with isolated facial edema complicated by acute respiratory failure: a case report.
BACKGROUND
In clinically amyopathic dermatomyositis, the hallmark cutaneous manifestations are the key to diagnosis. We report a case of clinically amyopathic dermatomyositis which presented with facial edema as the sole cutaneous manifestation and was later complicated by acute respiratory failure leading to death.
METHODS
A 58-year-old woman presented with edema of the face that had developed approximately one year ago. There was no weakness in the extremities, and the serum creatine kinase level was within normal range. On MRI, there was diffuse edematous change in the bilateral masticator and extra-ocular muscles, accompanied by subcutaneous fat infiltration in the face. A shared decision was made to defer muscle biopsy in the facial muscles. The facial swelling almost resolved with medium-dose glucocorticoid therapy but relapsed in days at glucocorticoid doses lower than 15 mg/day. Combination therapy with either azathioprine, mycophenolate, or methotrexate was not successful in maintaining clinical remission, and the swelling became more severe after relapses. A US-guided core-needle biopsy was subsequently performed in the right masseter muscle. On pathologic examination, there was a patchy CD4 + T cell-dominant lymphoplasmacytic infiltration in the stroma, necrosis of the myofibrils and prominent perifascicular atrophy. Based on those findings, a diagnosis of clinically amyopathic dermatomyositis was made. Therapy with gamma-globulin was not effective in maintaining remission. In the sixth week after starting rituximab, she presented to emergency room with altered mental state from acute respiratory failure. Despite treatment with antibiotics, glucocorticoid pulse, cyclosporin, and polymyxin B-immobilized fiber column direct hemoperfusion, she died three weeks later from persistent hypoxemic respiratory failure.
CONCLUSIONS
This case showed the full spectrum and severity of internal organ involvement of dermatomyositis, although the patient presented exclusively with subcutaneous edema limited to the head. The prognosis may be more closely associated with a specific auto-antibody profile than the benign-looking initial clinical manifestation. Close follow-up of lung involvement with prophylactic treatment for Pneumocystis pneumonia and prompt implementation of emerging therapeutic regimens may improve the outcome.
Background
Even before the classification of dermatomyositis (DM) was defined by Bohan and Peter in 1975, it was well known that there was a subgroup of patients who did not have muscle disease, regarded as amyopathic dermatomyositis (ADM)[1]. Studies have shown that there is evidence of subclinical muscle disease in MRI imaging and muscle biopsy in ADM leading to the concept of clinically amyopathic dermatomyositis (CADM), which is defined as absence of clinical muscle disease on physical examination and muscle enzyme analysis for at least six months[2]. In CADM, which represents about 11–20 % of dermatomyositis (DM)[3, 4], the hallmark cutaneous manifestations such as Heliotrope rash, Gottron’s papules, and Gottron’s sign are the key to diagnosis.
There has been a report that suggested that subcutaneous edema is a cutaneous manifestation of DM because it can be the only skin lesion at presentation[5]. In the case series, edematous DM comprised 6 % (5/86) of a DM cohort. In the muscle biopsies of the five cases of edematous DM, there were frequent microinfarctions, which were considered to be induced by vasculitis producing micro-ischemia. In the reported five cases and review of 19 reported cases, there were six cases (3/5 and 3/19, respectively) in which subcutaneous edema was the sole cutaneous manifestation, but all had clinical muscle disease, suggesting that CADM presenting exclusively with subcutaneous edema is very rare. In this study, we report a case of CADM which presented with facial edema as the sole cutaneous manifestation and was later complicated by acute respiratory failure leading to mortality.
Case presentation
A 58-year-old woman presented with edema of the face that had developed approximately one year prior. It was not painful nor pruritic, but she felt it was more prominent on the left side. Courses of antibiotic therapy for a presumed diagnosis of cellulitis had not been effective, but glucocorticoids greatly improved the swelling, which relapsed rapidly with tapering. One week prior, as another course of glucocorticoids prescribed for a diagnosis of angioedema was tapered out, her facial edema relapsed, accompanied by tiny, pruritic vesicular lesions on the chin. Although she was evaluated in neurology and dental clinics, no specific diagnosis was made. She reported ‘dryness’ and ‘itchiness’ of the eyes, but not in the oral cavity.
On evaluation, there was bilateral swelling of the malar and temporal area of the face, involving the periorbital area and eyelid in the left side. On the chin, there was eczematoid vesicular eruption (Fig. 1a). There was no abnormal finding on the examination of the chest and abdomen. There was no edema or rash in the trunk or extremities. Neck flexion was preserved, and the power of the extremities’ motor function was evaluated as five on a scale of zero to five. On ophthalmologic examination, there was swelling of the left upper eyelid, and the anterior chamber was clear and deep in both eyes. Five-minute Schirmer test result was 6 mm in the right eye and 8 mm in the left eye (reference value < 5 mm for dry eye disease, but known to have low sensitivity in mild or moderate cases)[6]. Ocular staining score was 1 and 2 in the right and left eye, respectively (reference value ≥ 5 for classification of primary Sjögren’s syndrome)[7].
Fig. 1 Isolated facial edema and subclinical facial muscle involvement. At initial presentation there was bilateral swelling of the face and of the left eyelid, accompanied by eczematoid eruption on the chin (a). After approximately two weeks of medium-dose glucocorticoid therapy the edema and the lesions were completely resolved (b). However, combination therapy with either azathioprine, mycophenolate, or methotrexate was not successful in maintaining remission at a prednisolone dose lower than 15 mg per day. At the last relapse, there was marked aggravation of facial and eyelid edema (c). Gadolinium-enhanced MRI scan of the head shows diffuse edematous change with enhancement of bilateral masticator muscles (d, masseter muscle [yellow arrow] and lateral pterygoid muscle [black arrow]). There was also swelling of bilateral extra-ocular muscles and edematous change with fat infiltration in the subcutaneous tissues of the anterior scalp, periorbital area, buccal space, and anterior cervical fascia (not shown)
On the initial laboratory evaluation, there were no abnormalities, and the serum creatine phosphokinase (CPK) level was within normal range (Table 1). On serologic evaluation, antinuclear antibody was positive up to 1:160 in titer in homogeneous pattern, but anti-dsDNA Ab and anti-histone Ab was negative. Anti-SSA (> 240 U/mL) and anti-SSB (18 U/mL) antibodies were positive (fluorescent enzyme immunoassay, reference value < 7 U/mL for both); anti-RNP and anti-Smith Ab, negative. Anti-Jo1 antibody and anti-SRP antibody were negative. Anti-neutrophil cytoplasmic antibody was negative and IgG4 level was within normal range: 102 mg/dL (reference 30 ~ 201 mg/dL).
Table 1 Laboratory data
Variable Reference range At initial presentation At the second admission
WBC 4.0 ~ 10.0 × 109/L 5.2 2.84
RBC 4.2 ~ 5.4 × 1012/L 4.23 4.38
Hgb 12.0 ~ 16.0 g/dL 12.4 13.7
Platelet 140 ~ 440 × 109/L 230 166
Differential Count
Neutrophil 40 ~ 80 % 57.8 66.8
Lymphocyte 15 ~ 50 % 30.2 20.8
Monocyte 2 ~ 11 % 7.9 9.2
Eosinophil 0 ~ 7 % 3.5 2.8
Basophil 0 ~ 1 % 0.6 0.4
ESR ~ 120 mm 14 21
Total Protein 6.0 ~ 8.0 g/dl 7.4 7.1
Albumin 3.5 ~ 5.2 g/dl 4.3 4.1
Total Bilirubin ~ 1.2 mg/dl 0.64 1.01
AST 7 ~ 38 U/L 36 50
ALT 4 ~ 43 U/L 32 69
ALP 36 ~ 104 U/L 79 58
Glucose 70 ~ 110 mg/dl 84 109
Total Cholesterol ~ 200 mg/dl 171 204
BUN 6.0 ~ 20.0 mg/dl 16 18.6
Creatinine 0.6 ~ 1.2 mg/dl 0.79 0.82
Direct Bilirubin ~ 0.3 mg/dl 0.19 0.24
LDH ~ 250 IU/L 269 424
CPK 50 ~ 200 U/L 182 317
Uric acid 3.0 ~ 5.5 mg/dl 3.5 3.4
CRP ~ 0.30 mg/dL 0.05 0.68
WBC white blood cell, RBC red blood cell, ESR erythrocyte sedimentation rate, AST aspartate aminotransferase, ALT alanine aminotransferase, ALP alkaline phosphatase, BUN blood urea nitrogen, LDH lactase dehydrogenase, CPK creatine phosphokinase, CRP C-reactive protein
On MRI, there was a diffuse edematous change in the bilateral masticator and extra-ocular muscles, accompanied by subcutaneous fat infiltration in the buccal and periorbital spaces. There was inhomogeneous enhancement of bilateral parotid glands. On PET-CT scan there was diffuse F-18-FDG uptake in the periorbital, frontalis, temporalis, and masseter muscles and the buccal and submandibular spaces without any increased uptake in the extremities or internal organs.
The Head and Neck Surgery and Radiology departments opined that a biopsy of the muscles would entail risk of complications such as bleeding and injury to the muscles. After a discussion with the patient regarding undergoing a muscle biopsy, a presumptive clinical diagnosis of an overlap syndrome of Sjogren’s syndrome with myositis was made and treatment with a medium-dose glucocorticoid (prednisolone 30 mg/day) begun; based on reports of orbital involvement, a good response to therapy, and benign prognosis in myositis associated with Sjogren’s syndrome[8–10]. On 16th day of treatment, the facial swelling was assessed as having completely resolved (Fig. 1b); however, the facial edema relapsed during subsequent days when glucocorticoid doses were lowered to less than 15 mg/day. Combination therapy with azathioprine, mycophenolate, or methotrexate for eight months was not effective in maintaining remission at acceptable doses of glucocorticoid, and the swelling aggravated considerably with the final relapse.
The patient finally agreed to further evaluation and was admitted to the hospital. On examination, there was aggravation of the facial edema (Fig. 1c). There was swelling of the right ankle, without tenderness. Neck flexion was preserved and motor power of extremities was assessed as five on a scale of zero to five. On laboratory evaluation, there was mild elevation of liver transaminases and CPK (Table 1). Serum aldolase was 7.9 U/L (reference < 7.6 U/L). On MRI of the head, there was aggravation of the inflammation (Fig. 1d). On ultrasonography of the right ankle, there was subcutaneous edema without evidence of synovitis. A series of evaluations to screen for malignancy including tumor makers (CA19-9, CEA, and CA125), esophagogastroduodenoscopy, colonoscopy, and mammography did not reveal abnormal findings.
A US-guided core-needle biopsy with an 18-gauge needle was performed in the right masseter muscle. Two pieces of tiny muscle tissue, measuring up to 0.5 × 0.1 cm, were obtained. On pathologic examination, there was moderate size variation of the myofibers, and endomysial and perimysial fibrosis. There was patchy CD4 + T cell-dominant lymphoplasmacytic infiltration in the stroma and atrophy of the myofibers, mainly at the periphery of the fascicles, being consistent with perifascicular atrophy. Necrosis of the myofibers was not prominent (Fig. 2). Based on these findings, a diagnosis of clinically amyopathic dermatomyositis was made.
Fig. 2 Biopsy specimens from the right masseter muscle. Hematoxylin and eosin staining shows moderate size variation of the myofibers and endomysial and perimysial fibrosis (white arrow). There is atrophy of the myofibers, mainly at the periphery of the fascicles (black arrow), which is consistent with perifascicular atrophy (a). Patchy lymphoplasmacytic infiltration (white arrow) is noted in the stroma (b), which consists of predominantly more CD4-positive cells (c) than CD8-positive cells (d) in immunohistochemical staining. All figures are at 200-fold magnification
Therapy with gamma-globulin (IVIG, 2.1 g/kg per month) in combination with prednisolone 30 mg/day was initiated, and after the first cycle the facial edema had resolved completely. However, when the dose of prednisolone was decreased to 15 mg/day, she made an earlier visit to the clinic with a relapse of the facial edema within six days. By the fourth cycle of IVIG, sustained remission could not be achieved. A course of rituximab (1.0 g twice, a week apart) in combination with methylprednisolone 40 mg/day was started. In the sixth week of rituximab therapy, when glucocorticoid dose was decreased to methylprednisolone 32 mg/day, she presented to the emergency room with altered mentality that began one day prior. On presentation, there was a fever of 38.7 °C, and the patient began mechanical ventilation immediately for hypoxemic respiratory failure. On chest X-ray, there was diffuse consolidation in both lung fields (Fig. 3b). On high-resolution CT, there was diffuse consolidation in the dependent portion of the lungs and diffuse ground glass opacity with relative sparing of the base of the lungs (Fig. 3c, d). The next day, the patient underwent bronchoscopy with bronchoalveolar lavage. The total cell count was 12 × 106 cells in 9 mL of fluid. Differential data of each cell type was as follows: macrophage 8 %, neutrophil 83 %, and lymphocyte 9 %. There was no bacteria isolated from the respiratory specimen, and a polymerase chain reaction (PCR) test for respiratory viruses including adenovirus, influenza virus, parainfluenza virus, and respiratory syncytial virus was negative. Pneumocystis jirovecii PCR and Gomori methenamine silver (GMS) staining were positive, and the patient began treatment with trimethoprim-sulfamethoxazole and glucocorticoids; but her hypoxemic respiratory failure progressed, and veno-venous extracorporeal (ECMO) membrane oxygenation was begun three days later. Given the lack of response to antibiotics therapy, glucocorticoid pulse and IV cyclosporine was started in consideration of rapidly progressive interstitial lung disease (RP-ILD). Over the next three weeks, despite the addition of polymyxin B-immobilized fiber column direct hemoperfusion (PMX-DHP)[11], there was no improvement in her hypoxemic respiratory failure, and according to the family’s will, the ECMO was weaned. On that day, she expired from respiratory failure.
Fig. 3 Chest radiographic images before and at the presentation of acute respiratory failure. Chest postero-anterior radiography taken about one month after initiating rituximab therapy shows no clear haziness or infiltration in both lung fields (a). At the presentation of acute respiratory failure with altered mentality (in the sixth week after starting rituximab) there was diffuse bilateral infiltration in both lung fields with relative sparing of both lower lung fields (b). Axial high-resolution computed tomography images show diffuse ground glass opacity in both upper lungs with consolidation in dependent areas (c); The lung base is relatively spared (d)
Discussion and Conclusions
This case, which posed significant diagnostic and therapeutic challenges, leaves important lessons for practice and research. First, isolated localized edema may be the initial manifestation of CADM. Such a case is considered very rare; we could find only one case reported in sufficient detail for us to verify the absence of muscle disease and other cutaneous manifestations, the prognosis of which was not known[12]. Second, although the patient presented initially with mild glucocorticoid-responsive facial edema, her course showed increasing extent of subcutaneous edema, decreasing response to immunomodulating therapy, and acute and severe involvement of the lungs leading to death. This suggests the prognosis cannot be predicted by the initially mild clinical manifestation alone.
Severe respiratory complications in idiopathic inflammatory myopathies such as DM pose considerable challenges to treatment, and the prognosis is poor[13, 14]. Differential diagnoses include cardiac complications, respiratory muscle weakness, drug hypersensitivity, RP-ILD, and severe and opportunistic infections[15, 16]. In many cases, it is difficult to arrive at a specific diagnosis, and there is a therapeutic dilemma of treating a severe autoimmune inflammation and a difficult-to-treat infection at the same time. Also in this case, there are a couple of explanations for the acute respiratory disease. First, the possibility of Pneumocystis pneumonia (PCP) should be considered. Prolonged glucocorticoid therapy is one of the risk factors for PCP in patients undergoing immunomodulating therapy for systemic autoimmune rheumatic diseases, and the patient was not receiving prophylaxis for it because of thrombocytopenia (< 50,000/mm3). Radiographic findings of acutely developed consolidation and ground glass opacity with relative sparing of the lung base is suggestive of PCP, and PCR and GMS staining were positive. In addition, even with appropriate treatment, mortality in fulminant PCP in non-HIV immunocompromised patients is high; in a recent study, the mortality rate in idiopathic inflammatory myopathy (including CADM) patients admitted to ICUs was 79.4 %, and PCP comprised approximately 20 % of the admissions[13]. Second, we believe the possibility of RP-ILD should be considered. From the early 2000s, associations between CADM and RP-ILD with poor prognosis were reported in Northeast Asia, including Korea, with mortality reaching approximately 50 %[17–19]. Later studies identified an association between anti-melanoma differentiation-associated protein 5 (MDA5) antibody and RP-ILD[20] [21], both of which are more common in CADM than in DM[22], and in Asians compared with Caucasians[21]. Recent studies report initial combination immunosuppressive therapies improved survival in RP-ILD in CADM[23], and that in the case of refractories a rescue therapy with tofacitinib may improve the outcome[24, 25]. Although we could not evaluate the presence of anti-MDA5 Ab in this case, which is a limitation of this study, rapidly progressive ILD was a possibility in the differential diagnosis of acute respiratory failure which did not respond to antibiotic therapy. Third, rituximab-induced lung disease could be considered. The patient developed acute respiratory symptoms five weeks and one day after the last rituximab infusion. This was in the period when late-onset respiratory illness may develop after rituximab infusion. However, late-onset rituximab-induced respiratory illness is less frequent than delayed-onset illness, shows a chronic course over weeks or months, and responds well to glucocorticoid therapy[26].
In conclusion, this case showed that CADM can initially manifest as a localized subcutaneous edema as the sole cutaneous manifestation but follow a progressive, refractory, and fatal course with major organ involvement, especially involving the lungs. A specific auto-antibody pattern may better predict the prognosis. Identification of the specific antibody profile and prompt initiation of therapy with proven efficacy may improve the outcome.
Authors’ contributions.
DHL analyzed clinical data and prepared the manuscript. YMK performed pathologic examination of the muscle biopsy samples and wrote the pathologic results. JHR performed the radiologic examination and muscle biopsy and contributed to writing. JHL, CSP, and SHK participated in critical care of the patient and contributed to writing. SL planned the study and performed analysis of data and literature. All authors read and approved the final manuscript.
Publisher’s Note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
Acknowledgements
Not applicable.
Authors' contributions
DHL analyzed clinical data and prepared the manuscript. YMK performed pathologic examination of the muscle biopsy samples and wrote the pathologic results. JHR performed the radiologic examination and muscle biopsy and contributed to writing. JHL, CSP, and SHK participated in critical care of the patient and contributed to writing. SL planned the study and performed analysis of data and literature. All authors read and approved the final manuscript.
Funding
Not applicable.
Availability of data and materials
Not applicable.
Ethics approval and consent to participate
This study was approved by the institutional review board of Haeundae Paik hospital (IRB file number: HPIRB 2019-08-016-001).
Consent for publication
Written informed consent was obtained from the patient, including the use of photographs of the face.
Competing interests
The authors declare that they have no competing interests. | AZATHIOPRINE, METHOTREXATE, METHYLPREDNISOLONE, MYCOPHENOLATE MOFETIL, PREDNISOLONE, RITUXIMAB | DrugsGivenReaction | CC BY | 33509162 | 19,217,583 | 2021-01-28 |
Give an alphabetized list of all active substances of drugs taken by the patient who experienced 'Respiratory failure'. | Clinically amyopathic dermatomyositis presenting with isolated facial edema complicated by acute respiratory failure: a case report.
BACKGROUND
In clinically amyopathic dermatomyositis, the hallmark cutaneous manifestations are the key to diagnosis. We report a case of clinically amyopathic dermatomyositis which presented with facial edema as the sole cutaneous manifestation and was later complicated by acute respiratory failure leading to death.
METHODS
A 58-year-old woman presented with edema of the face that had developed approximately one year ago. There was no weakness in the extremities, and the serum creatine kinase level was within normal range. On MRI, there was diffuse edematous change in the bilateral masticator and extra-ocular muscles, accompanied by subcutaneous fat infiltration in the face. A shared decision was made to defer muscle biopsy in the facial muscles. The facial swelling almost resolved with medium-dose glucocorticoid therapy but relapsed in days at glucocorticoid doses lower than 15 mg/day. Combination therapy with either azathioprine, mycophenolate, or methotrexate was not successful in maintaining clinical remission, and the swelling became more severe after relapses. A US-guided core-needle biopsy was subsequently performed in the right masseter muscle. On pathologic examination, there was a patchy CD4 + T cell-dominant lymphoplasmacytic infiltration in the stroma, necrosis of the myofibrils and prominent perifascicular atrophy. Based on those findings, a diagnosis of clinically amyopathic dermatomyositis was made. Therapy with gamma-globulin was not effective in maintaining remission. In the sixth week after starting rituximab, she presented to emergency room with altered mental state from acute respiratory failure. Despite treatment with antibiotics, glucocorticoid pulse, cyclosporin, and polymyxin B-immobilized fiber column direct hemoperfusion, she died three weeks later from persistent hypoxemic respiratory failure.
CONCLUSIONS
This case showed the full spectrum and severity of internal organ involvement of dermatomyositis, although the patient presented exclusively with subcutaneous edema limited to the head. The prognosis may be more closely associated with a specific auto-antibody profile than the benign-looking initial clinical manifestation. Close follow-up of lung involvement with prophylactic treatment for Pneumocystis pneumonia and prompt implementation of emerging therapeutic regimens may improve the outcome.
Background
Even before the classification of dermatomyositis (DM) was defined by Bohan and Peter in 1975, it was well known that there was a subgroup of patients who did not have muscle disease, regarded as amyopathic dermatomyositis (ADM)[1]. Studies have shown that there is evidence of subclinical muscle disease in MRI imaging and muscle biopsy in ADM leading to the concept of clinically amyopathic dermatomyositis (CADM), which is defined as absence of clinical muscle disease on physical examination and muscle enzyme analysis for at least six months[2]. In CADM, which represents about 11–20 % of dermatomyositis (DM)[3, 4], the hallmark cutaneous manifestations such as Heliotrope rash, Gottron’s papules, and Gottron’s sign are the key to diagnosis.
There has been a report that suggested that subcutaneous edema is a cutaneous manifestation of DM because it can be the only skin lesion at presentation[5]. In the case series, edematous DM comprised 6 % (5/86) of a DM cohort. In the muscle biopsies of the five cases of edematous DM, there were frequent microinfarctions, which were considered to be induced by vasculitis producing micro-ischemia. In the reported five cases and review of 19 reported cases, there were six cases (3/5 and 3/19, respectively) in which subcutaneous edema was the sole cutaneous manifestation, but all had clinical muscle disease, suggesting that CADM presenting exclusively with subcutaneous edema is very rare. In this study, we report a case of CADM which presented with facial edema as the sole cutaneous manifestation and was later complicated by acute respiratory failure leading to mortality.
Case presentation
A 58-year-old woman presented with edema of the face that had developed approximately one year prior. It was not painful nor pruritic, but she felt it was more prominent on the left side. Courses of antibiotic therapy for a presumed diagnosis of cellulitis had not been effective, but glucocorticoids greatly improved the swelling, which relapsed rapidly with tapering. One week prior, as another course of glucocorticoids prescribed for a diagnosis of angioedema was tapered out, her facial edema relapsed, accompanied by tiny, pruritic vesicular lesions on the chin. Although she was evaluated in neurology and dental clinics, no specific diagnosis was made. She reported ‘dryness’ and ‘itchiness’ of the eyes, but not in the oral cavity.
On evaluation, there was bilateral swelling of the malar and temporal area of the face, involving the periorbital area and eyelid in the left side. On the chin, there was eczematoid vesicular eruption (Fig. 1a). There was no abnormal finding on the examination of the chest and abdomen. There was no edema or rash in the trunk or extremities. Neck flexion was preserved, and the power of the extremities’ motor function was evaluated as five on a scale of zero to five. On ophthalmologic examination, there was swelling of the left upper eyelid, and the anterior chamber was clear and deep in both eyes. Five-minute Schirmer test result was 6 mm in the right eye and 8 mm in the left eye (reference value < 5 mm for dry eye disease, but known to have low sensitivity in mild or moderate cases)[6]. Ocular staining score was 1 and 2 in the right and left eye, respectively (reference value ≥ 5 for classification of primary Sjögren’s syndrome)[7].
Fig. 1 Isolated facial edema and subclinical facial muscle involvement. At initial presentation there was bilateral swelling of the face and of the left eyelid, accompanied by eczematoid eruption on the chin (a). After approximately two weeks of medium-dose glucocorticoid therapy the edema and the lesions were completely resolved (b). However, combination therapy with either azathioprine, mycophenolate, or methotrexate was not successful in maintaining remission at a prednisolone dose lower than 15 mg per day. At the last relapse, there was marked aggravation of facial and eyelid edema (c). Gadolinium-enhanced MRI scan of the head shows diffuse edematous change with enhancement of bilateral masticator muscles (d, masseter muscle [yellow arrow] and lateral pterygoid muscle [black arrow]). There was also swelling of bilateral extra-ocular muscles and edematous change with fat infiltration in the subcutaneous tissues of the anterior scalp, periorbital area, buccal space, and anterior cervical fascia (not shown)
On the initial laboratory evaluation, there were no abnormalities, and the serum creatine phosphokinase (CPK) level was within normal range (Table 1). On serologic evaluation, antinuclear antibody was positive up to 1:160 in titer in homogeneous pattern, but anti-dsDNA Ab and anti-histone Ab was negative. Anti-SSA (> 240 U/mL) and anti-SSB (18 U/mL) antibodies were positive (fluorescent enzyme immunoassay, reference value < 7 U/mL for both); anti-RNP and anti-Smith Ab, negative. Anti-Jo1 antibody and anti-SRP antibody were negative. Anti-neutrophil cytoplasmic antibody was negative and IgG4 level was within normal range: 102 mg/dL (reference 30 ~ 201 mg/dL).
Table 1 Laboratory data
Variable Reference range At initial presentation At the second admission
WBC 4.0 ~ 10.0 × 109/L 5.2 2.84
RBC 4.2 ~ 5.4 × 1012/L 4.23 4.38
Hgb 12.0 ~ 16.0 g/dL 12.4 13.7
Platelet 140 ~ 440 × 109/L 230 166
Differential Count
Neutrophil 40 ~ 80 % 57.8 66.8
Lymphocyte 15 ~ 50 % 30.2 20.8
Monocyte 2 ~ 11 % 7.9 9.2
Eosinophil 0 ~ 7 % 3.5 2.8
Basophil 0 ~ 1 % 0.6 0.4
ESR ~ 120 mm 14 21
Total Protein 6.0 ~ 8.0 g/dl 7.4 7.1
Albumin 3.5 ~ 5.2 g/dl 4.3 4.1
Total Bilirubin ~ 1.2 mg/dl 0.64 1.01
AST 7 ~ 38 U/L 36 50
ALT 4 ~ 43 U/L 32 69
ALP 36 ~ 104 U/L 79 58
Glucose 70 ~ 110 mg/dl 84 109
Total Cholesterol ~ 200 mg/dl 171 204
BUN 6.0 ~ 20.0 mg/dl 16 18.6
Creatinine 0.6 ~ 1.2 mg/dl 0.79 0.82
Direct Bilirubin ~ 0.3 mg/dl 0.19 0.24
LDH ~ 250 IU/L 269 424
CPK 50 ~ 200 U/L 182 317
Uric acid 3.0 ~ 5.5 mg/dl 3.5 3.4
CRP ~ 0.30 mg/dL 0.05 0.68
WBC white blood cell, RBC red blood cell, ESR erythrocyte sedimentation rate, AST aspartate aminotransferase, ALT alanine aminotransferase, ALP alkaline phosphatase, BUN blood urea nitrogen, LDH lactase dehydrogenase, CPK creatine phosphokinase, CRP C-reactive protein
On MRI, there was a diffuse edematous change in the bilateral masticator and extra-ocular muscles, accompanied by subcutaneous fat infiltration in the buccal and periorbital spaces. There was inhomogeneous enhancement of bilateral parotid glands. On PET-CT scan there was diffuse F-18-FDG uptake in the periorbital, frontalis, temporalis, and masseter muscles and the buccal and submandibular spaces without any increased uptake in the extremities or internal organs.
The Head and Neck Surgery and Radiology departments opined that a biopsy of the muscles would entail risk of complications such as bleeding and injury to the muscles. After a discussion with the patient regarding undergoing a muscle biopsy, a presumptive clinical diagnosis of an overlap syndrome of Sjogren’s syndrome with myositis was made and treatment with a medium-dose glucocorticoid (prednisolone 30 mg/day) begun; based on reports of orbital involvement, a good response to therapy, and benign prognosis in myositis associated with Sjogren’s syndrome[8–10]. On 16th day of treatment, the facial swelling was assessed as having completely resolved (Fig. 1b); however, the facial edema relapsed during subsequent days when glucocorticoid doses were lowered to less than 15 mg/day. Combination therapy with azathioprine, mycophenolate, or methotrexate for eight months was not effective in maintaining remission at acceptable doses of glucocorticoid, and the swelling aggravated considerably with the final relapse.
The patient finally agreed to further evaluation and was admitted to the hospital. On examination, there was aggravation of the facial edema (Fig. 1c). There was swelling of the right ankle, without tenderness. Neck flexion was preserved and motor power of extremities was assessed as five on a scale of zero to five. On laboratory evaluation, there was mild elevation of liver transaminases and CPK (Table 1). Serum aldolase was 7.9 U/L (reference < 7.6 U/L). On MRI of the head, there was aggravation of the inflammation (Fig. 1d). On ultrasonography of the right ankle, there was subcutaneous edema without evidence of synovitis. A series of evaluations to screen for malignancy including tumor makers (CA19-9, CEA, and CA125), esophagogastroduodenoscopy, colonoscopy, and mammography did not reveal abnormal findings.
A US-guided core-needle biopsy with an 18-gauge needle was performed in the right masseter muscle. Two pieces of tiny muscle tissue, measuring up to 0.5 × 0.1 cm, were obtained. On pathologic examination, there was moderate size variation of the myofibers, and endomysial and perimysial fibrosis. There was patchy CD4 + T cell-dominant lymphoplasmacytic infiltration in the stroma and atrophy of the myofibers, mainly at the periphery of the fascicles, being consistent with perifascicular atrophy. Necrosis of the myofibers was not prominent (Fig. 2). Based on these findings, a diagnosis of clinically amyopathic dermatomyositis was made.
Fig. 2 Biopsy specimens from the right masseter muscle. Hematoxylin and eosin staining shows moderate size variation of the myofibers and endomysial and perimysial fibrosis (white arrow). There is atrophy of the myofibers, mainly at the periphery of the fascicles (black arrow), which is consistent with perifascicular atrophy (a). Patchy lymphoplasmacytic infiltration (white arrow) is noted in the stroma (b), which consists of predominantly more CD4-positive cells (c) than CD8-positive cells (d) in immunohistochemical staining. All figures are at 200-fold magnification
Therapy with gamma-globulin (IVIG, 2.1 g/kg per month) in combination with prednisolone 30 mg/day was initiated, and after the first cycle the facial edema had resolved completely. However, when the dose of prednisolone was decreased to 15 mg/day, she made an earlier visit to the clinic with a relapse of the facial edema within six days. By the fourth cycle of IVIG, sustained remission could not be achieved. A course of rituximab (1.0 g twice, a week apart) in combination with methylprednisolone 40 mg/day was started. In the sixth week of rituximab therapy, when glucocorticoid dose was decreased to methylprednisolone 32 mg/day, she presented to the emergency room with altered mentality that began one day prior. On presentation, there was a fever of 38.7 °C, and the patient began mechanical ventilation immediately for hypoxemic respiratory failure. On chest X-ray, there was diffuse consolidation in both lung fields (Fig. 3b). On high-resolution CT, there was diffuse consolidation in the dependent portion of the lungs and diffuse ground glass opacity with relative sparing of the base of the lungs (Fig. 3c, d). The next day, the patient underwent bronchoscopy with bronchoalveolar lavage. The total cell count was 12 × 106 cells in 9 mL of fluid. Differential data of each cell type was as follows: macrophage 8 %, neutrophil 83 %, and lymphocyte 9 %. There was no bacteria isolated from the respiratory specimen, and a polymerase chain reaction (PCR) test for respiratory viruses including adenovirus, influenza virus, parainfluenza virus, and respiratory syncytial virus was negative. Pneumocystis jirovecii PCR and Gomori methenamine silver (GMS) staining were positive, and the patient began treatment with trimethoprim-sulfamethoxazole and glucocorticoids; but her hypoxemic respiratory failure progressed, and veno-venous extracorporeal (ECMO) membrane oxygenation was begun three days later. Given the lack of response to antibiotics therapy, glucocorticoid pulse and IV cyclosporine was started in consideration of rapidly progressive interstitial lung disease (RP-ILD). Over the next three weeks, despite the addition of polymyxin B-immobilized fiber column direct hemoperfusion (PMX-DHP)[11], there was no improvement in her hypoxemic respiratory failure, and according to the family’s will, the ECMO was weaned. On that day, she expired from respiratory failure.
Fig. 3 Chest radiographic images before and at the presentation of acute respiratory failure. Chest postero-anterior radiography taken about one month after initiating rituximab therapy shows no clear haziness or infiltration in both lung fields (a). At the presentation of acute respiratory failure with altered mentality (in the sixth week after starting rituximab) there was diffuse bilateral infiltration in both lung fields with relative sparing of both lower lung fields (b). Axial high-resolution computed tomography images show diffuse ground glass opacity in both upper lungs with consolidation in dependent areas (c); The lung base is relatively spared (d)
Discussion and Conclusions
This case, which posed significant diagnostic and therapeutic challenges, leaves important lessons for practice and research. First, isolated localized edema may be the initial manifestation of CADM. Such a case is considered very rare; we could find only one case reported in sufficient detail for us to verify the absence of muscle disease and other cutaneous manifestations, the prognosis of which was not known[12]. Second, although the patient presented initially with mild glucocorticoid-responsive facial edema, her course showed increasing extent of subcutaneous edema, decreasing response to immunomodulating therapy, and acute and severe involvement of the lungs leading to death. This suggests the prognosis cannot be predicted by the initially mild clinical manifestation alone.
Severe respiratory complications in idiopathic inflammatory myopathies such as DM pose considerable challenges to treatment, and the prognosis is poor[13, 14]. Differential diagnoses include cardiac complications, respiratory muscle weakness, drug hypersensitivity, RP-ILD, and severe and opportunistic infections[15, 16]. In many cases, it is difficult to arrive at a specific diagnosis, and there is a therapeutic dilemma of treating a severe autoimmune inflammation and a difficult-to-treat infection at the same time. Also in this case, there are a couple of explanations for the acute respiratory disease. First, the possibility of Pneumocystis pneumonia (PCP) should be considered. Prolonged glucocorticoid therapy is one of the risk factors for PCP in patients undergoing immunomodulating therapy for systemic autoimmune rheumatic diseases, and the patient was not receiving prophylaxis for it because of thrombocytopenia (< 50,000/mm3). Radiographic findings of acutely developed consolidation and ground glass opacity with relative sparing of the lung base is suggestive of PCP, and PCR and GMS staining were positive. In addition, even with appropriate treatment, mortality in fulminant PCP in non-HIV immunocompromised patients is high; in a recent study, the mortality rate in idiopathic inflammatory myopathy (including CADM) patients admitted to ICUs was 79.4 %, and PCP comprised approximately 20 % of the admissions[13]. Second, we believe the possibility of RP-ILD should be considered. From the early 2000s, associations between CADM and RP-ILD with poor prognosis were reported in Northeast Asia, including Korea, with mortality reaching approximately 50 %[17–19]. Later studies identified an association between anti-melanoma differentiation-associated protein 5 (MDA5) antibody and RP-ILD[20] [21], both of which are more common in CADM than in DM[22], and in Asians compared with Caucasians[21]. Recent studies report initial combination immunosuppressive therapies improved survival in RP-ILD in CADM[23], and that in the case of refractories a rescue therapy with tofacitinib may improve the outcome[24, 25]. Although we could not evaluate the presence of anti-MDA5 Ab in this case, which is a limitation of this study, rapidly progressive ILD was a possibility in the differential diagnosis of acute respiratory failure which did not respond to antibiotic therapy. Third, rituximab-induced lung disease could be considered. The patient developed acute respiratory symptoms five weeks and one day after the last rituximab infusion. This was in the period when late-onset respiratory illness may develop after rituximab infusion. However, late-onset rituximab-induced respiratory illness is less frequent than delayed-onset illness, shows a chronic course over weeks or months, and responds well to glucocorticoid therapy[26].
In conclusion, this case showed that CADM can initially manifest as a localized subcutaneous edema as the sole cutaneous manifestation but follow a progressive, refractory, and fatal course with major organ involvement, especially involving the lungs. A specific auto-antibody pattern may better predict the prognosis. Identification of the specific antibody profile and prompt initiation of therapy with proven efficacy may improve the outcome.
Authors’ contributions.
DHL analyzed clinical data and prepared the manuscript. YMK performed pathologic examination of the muscle biopsy samples and wrote the pathologic results. JHR performed the radiologic examination and muscle biopsy and contributed to writing. JHL, CSP, and SHK participated in critical care of the patient and contributed to writing. SL planned the study and performed analysis of data and literature. All authors read and approved the final manuscript.
Publisher’s Note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
Acknowledgements
Not applicable.
Authors' contributions
DHL analyzed clinical data and prepared the manuscript. YMK performed pathologic examination of the muscle biopsy samples and wrote the pathologic results. JHR performed the radiologic examination and muscle biopsy and contributed to writing. JHL, CSP, and SHK participated in critical care of the patient and contributed to writing. SL planned the study and performed analysis of data and literature. All authors read and approved the final manuscript.
Funding
Not applicable.
Availability of data and materials
Not applicable.
Ethics approval and consent to participate
This study was approved by the institutional review board of Haeundae Paik hospital (IRB file number: HPIRB 2019-08-016-001).
Consent for publication
Written informed consent was obtained from the patient, including the use of photographs of the face.
Competing interests
The authors declare that they have no competing interests. | AZATHIOPRINE, METHOTREXATE, METHYLPREDNISOLONE, MYCOPHENOLATE MOFETIL, PREDNISOLONE, RITUXIMAB | DrugsGivenReaction | CC BY | 33509162 | 19,217,583 | 2021-01-28 |
What was the administration route of drug 'HUMAN IMMUNOGLOBULIN G'? | Clinically amyopathic dermatomyositis presenting with isolated facial edema complicated by acute respiratory failure: a case report.
BACKGROUND
In clinically amyopathic dermatomyositis, the hallmark cutaneous manifestations are the key to diagnosis. We report a case of clinically amyopathic dermatomyositis which presented with facial edema as the sole cutaneous manifestation and was later complicated by acute respiratory failure leading to death.
METHODS
A 58-year-old woman presented with edema of the face that had developed approximately one year ago. There was no weakness in the extremities, and the serum creatine kinase level was within normal range. On MRI, there was diffuse edematous change in the bilateral masticator and extra-ocular muscles, accompanied by subcutaneous fat infiltration in the face. A shared decision was made to defer muscle biopsy in the facial muscles. The facial swelling almost resolved with medium-dose glucocorticoid therapy but relapsed in days at glucocorticoid doses lower than 15 mg/day. Combination therapy with either azathioprine, mycophenolate, or methotrexate was not successful in maintaining clinical remission, and the swelling became more severe after relapses. A US-guided core-needle biopsy was subsequently performed in the right masseter muscle. On pathologic examination, there was a patchy CD4 + T cell-dominant lymphoplasmacytic infiltration in the stroma, necrosis of the myofibrils and prominent perifascicular atrophy. Based on those findings, a diagnosis of clinically amyopathic dermatomyositis was made. Therapy with gamma-globulin was not effective in maintaining remission. In the sixth week after starting rituximab, she presented to emergency room with altered mental state from acute respiratory failure. Despite treatment with antibiotics, glucocorticoid pulse, cyclosporin, and polymyxin B-immobilized fiber column direct hemoperfusion, she died three weeks later from persistent hypoxemic respiratory failure.
CONCLUSIONS
This case showed the full spectrum and severity of internal organ involvement of dermatomyositis, although the patient presented exclusively with subcutaneous edema limited to the head. The prognosis may be more closely associated with a specific auto-antibody profile than the benign-looking initial clinical manifestation. Close follow-up of lung involvement with prophylactic treatment for Pneumocystis pneumonia and prompt implementation of emerging therapeutic regimens may improve the outcome.
Background
Even before the classification of dermatomyositis (DM) was defined by Bohan and Peter in 1975, it was well known that there was a subgroup of patients who did not have muscle disease, regarded as amyopathic dermatomyositis (ADM)[1]. Studies have shown that there is evidence of subclinical muscle disease in MRI imaging and muscle biopsy in ADM leading to the concept of clinically amyopathic dermatomyositis (CADM), which is defined as absence of clinical muscle disease on physical examination and muscle enzyme analysis for at least six months[2]. In CADM, which represents about 11–20 % of dermatomyositis (DM)[3, 4], the hallmark cutaneous manifestations such as Heliotrope rash, Gottron’s papules, and Gottron’s sign are the key to diagnosis.
There has been a report that suggested that subcutaneous edema is a cutaneous manifestation of DM because it can be the only skin lesion at presentation[5]. In the case series, edematous DM comprised 6 % (5/86) of a DM cohort. In the muscle biopsies of the five cases of edematous DM, there were frequent microinfarctions, which were considered to be induced by vasculitis producing micro-ischemia. In the reported five cases and review of 19 reported cases, there were six cases (3/5 and 3/19, respectively) in which subcutaneous edema was the sole cutaneous manifestation, but all had clinical muscle disease, suggesting that CADM presenting exclusively with subcutaneous edema is very rare. In this study, we report a case of CADM which presented with facial edema as the sole cutaneous manifestation and was later complicated by acute respiratory failure leading to mortality.
Case presentation
A 58-year-old woman presented with edema of the face that had developed approximately one year prior. It was not painful nor pruritic, but she felt it was more prominent on the left side. Courses of antibiotic therapy for a presumed diagnosis of cellulitis had not been effective, but glucocorticoids greatly improved the swelling, which relapsed rapidly with tapering. One week prior, as another course of glucocorticoids prescribed for a diagnosis of angioedema was tapered out, her facial edema relapsed, accompanied by tiny, pruritic vesicular lesions on the chin. Although she was evaluated in neurology and dental clinics, no specific diagnosis was made. She reported ‘dryness’ and ‘itchiness’ of the eyes, but not in the oral cavity.
On evaluation, there was bilateral swelling of the malar and temporal area of the face, involving the periorbital area and eyelid in the left side. On the chin, there was eczematoid vesicular eruption (Fig. 1a). There was no abnormal finding on the examination of the chest and abdomen. There was no edema or rash in the trunk or extremities. Neck flexion was preserved, and the power of the extremities’ motor function was evaluated as five on a scale of zero to five. On ophthalmologic examination, there was swelling of the left upper eyelid, and the anterior chamber was clear and deep in both eyes. Five-minute Schirmer test result was 6 mm in the right eye and 8 mm in the left eye (reference value < 5 mm for dry eye disease, but known to have low sensitivity in mild or moderate cases)[6]. Ocular staining score was 1 and 2 in the right and left eye, respectively (reference value ≥ 5 for classification of primary Sjögren’s syndrome)[7].
Fig. 1 Isolated facial edema and subclinical facial muscle involvement. At initial presentation there was bilateral swelling of the face and of the left eyelid, accompanied by eczematoid eruption on the chin (a). After approximately two weeks of medium-dose glucocorticoid therapy the edema and the lesions were completely resolved (b). However, combination therapy with either azathioprine, mycophenolate, or methotrexate was not successful in maintaining remission at a prednisolone dose lower than 15 mg per day. At the last relapse, there was marked aggravation of facial and eyelid edema (c). Gadolinium-enhanced MRI scan of the head shows diffuse edematous change with enhancement of bilateral masticator muscles (d, masseter muscle [yellow arrow] and lateral pterygoid muscle [black arrow]). There was also swelling of bilateral extra-ocular muscles and edematous change with fat infiltration in the subcutaneous tissues of the anterior scalp, periorbital area, buccal space, and anterior cervical fascia (not shown)
On the initial laboratory evaluation, there were no abnormalities, and the serum creatine phosphokinase (CPK) level was within normal range (Table 1). On serologic evaluation, antinuclear antibody was positive up to 1:160 in titer in homogeneous pattern, but anti-dsDNA Ab and anti-histone Ab was negative. Anti-SSA (> 240 U/mL) and anti-SSB (18 U/mL) antibodies were positive (fluorescent enzyme immunoassay, reference value < 7 U/mL for both); anti-RNP and anti-Smith Ab, negative. Anti-Jo1 antibody and anti-SRP antibody were negative. Anti-neutrophil cytoplasmic antibody was negative and IgG4 level was within normal range: 102 mg/dL (reference 30 ~ 201 mg/dL).
Table 1 Laboratory data
Variable Reference range At initial presentation At the second admission
WBC 4.0 ~ 10.0 × 109/L 5.2 2.84
RBC 4.2 ~ 5.4 × 1012/L 4.23 4.38
Hgb 12.0 ~ 16.0 g/dL 12.4 13.7
Platelet 140 ~ 440 × 109/L 230 166
Differential Count
Neutrophil 40 ~ 80 % 57.8 66.8
Lymphocyte 15 ~ 50 % 30.2 20.8
Monocyte 2 ~ 11 % 7.9 9.2
Eosinophil 0 ~ 7 % 3.5 2.8
Basophil 0 ~ 1 % 0.6 0.4
ESR ~ 120 mm 14 21
Total Protein 6.0 ~ 8.0 g/dl 7.4 7.1
Albumin 3.5 ~ 5.2 g/dl 4.3 4.1
Total Bilirubin ~ 1.2 mg/dl 0.64 1.01
AST 7 ~ 38 U/L 36 50
ALT 4 ~ 43 U/L 32 69
ALP 36 ~ 104 U/L 79 58
Glucose 70 ~ 110 mg/dl 84 109
Total Cholesterol ~ 200 mg/dl 171 204
BUN 6.0 ~ 20.0 mg/dl 16 18.6
Creatinine 0.6 ~ 1.2 mg/dl 0.79 0.82
Direct Bilirubin ~ 0.3 mg/dl 0.19 0.24
LDH ~ 250 IU/L 269 424
CPK 50 ~ 200 U/L 182 317
Uric acid 3.0 ~ 5.5 mg/dl 3.5 3.4
CRP ~ 0.30 mg/dL 0.05 0.68
WBC white blood cell, RBC red blood cell, ESR erythrocyte sedimentation rate, AST aspartate aminotransferase, ALT alanine aminotransferase, ALP alkaline phosphatase, BUN blood urea nitrogen, LDH lactase dehydrogenase, CPK creatine phosphokinase, CRP C-reactive protein
On MRI, there was a diffuse edematous change in the bilateral masticator and extra-ocular muscles, accompanied by subcutaneous fat infiltration in the buccal and periorbital spaces. There was inhomogeneous enhancement of bilateral parotid glands. On PET-CT scan there was diffuse F-18-FDG uptake in the periorbital, frontalis, temporalis, and masseter muscles and the buccal and submandibular spaces without any increased uptake in the extremities or internal organs.
The Head and Neck Surgery and Radiology departments opined that a biopsy of the muscles would entail risk of complications such as bleeding and injury to the muscles. After a discussion with the patient regarding undergoing a muscle biopsy, a presumptive clinical diagnosis of an overlap syndrome of Sjogren’s syndrome with myositis was made and treatment with a medium-dose glucocorticoid (prednisolone 30 mg/day) begun; based on reports of orbital involvement, a good response to therapy, and benign prognosis in myositis associated with Sjogren’s syndrome[8–10]. On 16th day of treatment, the facial swelling was assessed as having completely resolved (Fig. 1b); however, the facial edema relapsed during subsequent days when glucocorticoid doses were lowered to less than 15 mg/day. Combination therapy with azathioprine, mycophenolate, or methotrexate for eight months was not effective in maintaining remission at acceptable doses of glucocorticoid, and the swelling aggravated considerably with the final relapse.
The patient finally agreed to further evaluation and was admitted to the hospital. On examination, there was aggravation of the facial edema (Fig. 1c). There was swelling of the right ankle, without tenderness. Neck flexion was preserved and motor power of extremities was assessed as five on a scale of zero to five. On laboratory evaluation, there was mild elevation of liver transaminases and CPK (Table 1). Serum aldolase was 7.9 U/L (reference < 7.6 U/L). On MRI of the head, there was aggravation of the inflammation (Fig. 1d). On ultrasonography of the right ankle, there was subcutaneous edema without evidence of synovitis. A series of evaluations to screen for malignancy including tumor makers (CA19-9, CEA, and CA125), esophagogastroduodenoscopy, colonoscopy, and mammography did not reveal abnormal findings.
A US-guided core-needle biopsy with an 18-gauge needle was performed in the right masseter muscle. Two pieces of tiny muscle tissue, measuring up to 0.5 × 0.1 cm, were obtained. On pathologic examination, there was moderate size variation of the myofibers, and endomysial and perimysial fibrosis. There was patchy CD4 + T cell-dominant lymphoplasmacytic infiltration in the stroma and atrophy of the myofibers, mainly at the periphery of the fascicles, being consistent with perifascicular atrophy. Necrosis of the myofibers was not prominent (Fig. 2). Based on these findings, a diagnosis of clinically amyopathic dermatomyositis was made.
Fig. 2 Biopsy specimens from the right masseter muscle. Hematoxylin and eosin staining shows moderate size variation of the myofibers and endomysial and perimysial fibrosis (white arrow). There is atrophy of the myofibers, mainly at the periphery of the fascicles (black arrow), which is consistent with perifascicular atrophy (a). Patchy lymphoplasmacytic infiltration (white arrow) is noted in the stroma (b), which consists of predominantly more CD4-positive cells (c) than CD8-positive cells (d) in immunohistochemical staining. All figures are at 200-fold magnification
Therapy with gamma-globulin (IVIG, 2.1 g/kg per month) in combination with prednisolone 30 mg/day was initiated, and after the first cycle the facial edema had resolved completely. However, when the dose of prednisolone was decreased to 15 mg/day, she made an earlier visit to the clinic with a relapse of the facial edema within six days. By the fourth cycle of IVIG, sustained remission could not be achieved. A course of rituximab (1.0 g twice, a week apart) in combination with methylprednisolone 40 mg/day was started. In the sixth week of rituximab therapy, when glucocorticoid dose was decreased to methylprednisolone 32 mg/day, she presented to the emergency room with altered mentality that began one day prior. On presentation, there was a fever of 38.7 °C, and the patient began mechanical ventilation immediately for hypoxemic respiratory failure. On chest X-ray, there was diffuse consolidation in both lung fields (Fig. 3b). On high-resolution CT, there was diffuse consolidation in the dependent portion of the lungs and diffuse ground glass opacity with relative sparing of the base of the lungs (Fig. 3c, d). The next day, the patient underwent bronchoscopy with bronchoalveolar lavage. The total cell count was 12 × 106 cells in 9 mL of fluid. Differential data of each cell type was as follows: macrophage 8 %, neutrophil 83 %, and lymphocyte 9 %. There was no bacteria isolated from the respiratory specimen, and a polymerase chain reaction (PCR) test for respiratory viruses including adenovirus, influenza virus, parainfluenza virus, and respiratory syncytial virus was negative. Pneumocystis jirovecii PCR and Gomori methenamine silver (GMS) staining were positive, and the patient began treatment with trimethoprim-sulfamethoxazole and glucocorticoids; but her hypoxemic respiratory failure progressed, and veno-venous extracorporeal (ECMO) membrane oxygenation was begun three days later. Given the lack of response to antibiotics therapy, glucocorticoid pulse and IV cyclosporine was started in consideration of rapidly progressive interstitial lung disease (RP-ILD). Over the next three weeks, despite the addition of polymyxin B-immobilized fiber column direct hemoperfusion (PMX-DHP)[11], there was no improvement in her hypoxemic respiratory failure, and according to the family’s will, the ECMO was weaned. On that day, she expired from respiratory failure.
Fig. 3 Chest radiographic images before and at the presentation of acute respiratory failure. Chest postero-anterior radiography taken about one month after initiating rituximab therapy shows no clear haziness or infiltration in both lung fields (a). At the presentation of acute respiratory failure with altered mentality (in the sixth week after starting rituximab) there was diffuse bilateral infiltration in both lung fields with relative sparing of both lower lung fields (b). Axial high-resolution computed tomography images show diffuse ground glass opacity in both upper lungs with consolidation in dependent areas (c); The lung base is relatively spared (d)
Discussion and Conclusions
This case, which posed significant diagnostic and therapeutic challenges, leaves important lessons for practice and research. First, isolated localized edema may be the initial manifestation of CADM. Such a case is considered very rare; we could find only one case reported in sufficient detail for us to verify the absence of muscle disease and other cutaneous manifestations, the prognosis of which was not known[12]. Second, although the patient presented initially with mild glucocorticoid-responsive facial edema, her course showed increasing extent of subcutaneous edema, decreasing response to immunomodulating therapy, and acute and severe involvement of the lungs leading to death. This suggests the prognosis cannot be predicted by the initially mild clinical manifestation alone.
Severe respiratory complications in idiopathic inflammatory myopathies such as DM pose considerable challenges to treatment, and the prognosis is poor[13, 14]. Differential diagnoses include cardiac complications, respiratory muscle weakness, drug hypersensitivity, RP-ILD, and severe and opportunistic infections[15, 16]. In many cases, it is difficult to arrive at a specific diagnosis, and there is a therapeutic dilemma of treating a severe autoimmune inflammation and a difficult-to-treat infection at the same time. Also in this case, there are a couple of explanations for the acute respiratory disease. First, the possibility of Pneumocystis pneumonia (PCP) should be considered. Prolonged glucocorticoid therapy is one of the risk factors for PCP in patients undergoing immunomodulating therapy for systemic autoimmune rheumatic diseases, and the patient was not receiving prophylaxis for it because of thrombocytopenia (< 50,000/mm3). Radiographic findings of acutely developed consolidation and ground glass opacity with relative sparing of the lung base is suggestive of PCP, and PCR and GMS staining were positive. In addition, even with appropriate treatment, mortality in fulminant PCP in non-HIV immunocompromised patients is high; in a recent study, the mortality rate in idiopathic inflammatory myopathy (including CADM) patients admitted to ICUs was 79.4 %, and PCP comprised approximately 20 % of the admissions[13]. Second, we believe the possibility of RP-ILD should be considered. From the early 2000s, associations between CADM and RP-ILD with poor prognosis were reported in Northeast Asia, including Korea, with mortality reaching approximately 50 %[17–19]. Later studies identified an association between anti-melanoma differentiation-associated protein 5 (MDA5) antibody and RP-ILD[20] [21], both of which are more common in CADM than in DM[22], and in Asians compared with Caucasians[21]. Recent studies report initial combination immunosuppressive therapies improved survival in RP-ILD in CADM[23], and that in the case of refractories a rescue therapy with tofacitinib may improve the outcome[24, 25]. Although we could not evaluate the presence of anti-MDA5 Ab in this case, which is a limitation of this study, rapidly progressive ILD was a possibility in the differential diagnosis of acute respiratory failure which did not respond to antibiotic therapy. Third, rituximab-induced lung disease could be considered. The patient developed acute respiratory symptoms five weeks and one day after the last rituximab infusion. This was in the period when late-onset respiratory illness may develop after rituximab infusion. However, late-onset rituximab-induced respiratory illness is less frequent than delayed-onset illness, shows a chronic course over weeks or months, and responds well to glucocorticoid therapy[26].
In conclusion, this case showed that CADM can initially manifest as a localized subcutaneous edema as the sole cutaneous manifestation but follow a progressive, refractory, and fatal course with major organ involvement, especially involving the lungs. A specific auto-antibody pattern may better predict the prognosis. Identification of the specific antibody profile and prompt initiation of therapy with proven efficacy may improve the outcome.
Authors’ contributions.
DHL analyzed clinical data and prepared the manuscript. YMK performed pathologic examination of the muscle biopsy samples and wrote the pathologic results. JHR performed the radiologic examination and muscle biopsy and contributed to writing. JHL, CSP, and SHK participated in critical care of the patient and contributed to writing. SL planned the study and performed analysis of data and literature. All authors read and approved the final manuscript.
Publisher’s Note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
Acknowledgements
Not applicable.
Authors' contributions
DHL analyzed clinical data and prepared the manuscript. YMK performed pathologic examination of the muscle biopsy samples and wrote the pathologic results. JHR performed the radiologic examination and muscle biopsy and contributed to writing. JHL, CSP, and SHK participated in critical care of the patient and contributed to writing. SL planned the study and performed analysis of data and literature. All authors read and approved the final manuscript.
Funding
Not applicable.
Availability of data and materials
Not applicable.
Ethics approval and consent to participate
This study was approved by the institutional review board of Haeundae Paik hospital (IRB file number: HPIRB 2019-08-016-001).
Consent for publication
Written informed consent was obtained from the patient, including the use of photographs of the face.
Competing interests
The authors declare that they have no competing interests. | Intravenous (not otherwise specified) | DrugAdministrationRoute | CC BY | 33509162 | 18,862,926 | 2021-01-28 |
What was the dosage of drug 'HUMAN IMMUNOGLOBULIN G'? | Clinically amyopathic dermatomyositis presenting with isolated facial edema complicated by acute respiratory failure: a case report.
BACKGROUND
In clinically amyopathic dermatomyositis, the hallmark cutaneous manifestations are the key to diagnosis. We report a case of clinically amyopathic dermatomyositis which presented with facial edema as the sole cutaneous manifestation and was later complicated by acute respiratory failure leading to death.
METHODS
A 58-year-old woman presented with edema of the face that had developed approximately one year ago. There was no weakness in the extremities, and the serum creatine kinase level was within normal range. On MRI, there was diffuse edematous change in the bilateral masticator and extra-ocular muscles, accompanied by subcutaneous fat infiltration in the face. A shared decision was made to defer muscle biopsy in the facial muscles. The facial swelling almost resolved with medium-dose glucocorticoid therapy but relapsed in days at glucocorticoid doses lower than 15 mg/day. Combination therapy with either azathioprine, mycophenolate, or methotrexate was not successful in maintaining clinical remission, and the swelling became more severe after relapses. A US-guided core-needle biopsy was subsequently performed in the right masseter muscle. On pathologic examination, there was a patchy CD4 + T cell-dominant lymphoplasmacytic infiltration in the stroma, necrosis of the myofibrils and prominent perifascicular atrophy. Based on those findings, a diagnosis of clinically amyopathic dermatomyositis was made. Therapy with gamma-globulin was not effective in maintaining remission. In the sixth week after starting rituximab, she presented to emergency room with altered mental state from acute respiratory failure. Despite treatment with antibiotics, glucocorticoid pulse, cyclosporin, and polymyxin B-immobilized fiber column direct hemoperfusion, she died three weeks later from persistent hypoxemic respiratory failure.
CONCLUSIONS
This case showed the full spectrum and severity of internal organ involvement of dermatomyositis, although the patient presented exclusively with subcutaneous edema limited to the head. The prognosis may be more closely associated with a specific auto-antibody profile than the benign-looking initial clinical manifestation. Close follow-up of lung involvement with prophylactic treatment for Pneumocystis pneumonia and prompt implementation of emerging therapeutic regimens may improve the outcome.
Background
Even before the classification of dermatomyositis (DM) was defined by Bohan and Peter in 1975, it was well known that there was a subgroup of patients who did not have muscle disease, regarded as amyopathic dermatomyositis (ADM)[1]. Studies have shown that there is evidence of subclinical muscle disease in MRI imaging and muscle biopsy in ADM leading to the concept of clinically amyopathic dermatomyositis (CADM), which is defined as absence of clinical muscle disease on physical examination and muscle enzyme analysis for at least six months[2]. In CADM, which represents about 11–20 % of dermatomyositis (DM)[3, 4], the hallmark cutaneous manifestations such as Heliotrope rash, Gottron’s papules, and Gottron’s sign are the key to diagnosis.
There has been a report that suggested that subcutaneous edema is a cutaneous manifestation of DM because it can be the only skin lesion at presentation[5]. In the case series, edematous DM comprised 6 % (5/86) of a DM cohort. In the muscle biopsies of the five cases of edematous DM, there were frequent microinfarctions, which were considered to be induced by vasculitis producing micro-ischemia. In the reported five cases and review of 19 reported cases, there were six cases (3/5 and 3/19, respectively) in which subcutaneous edema was the sole cutaneous manifestation, but all had clinical muscle disease, suggesting that CADM presenting exclusively with subcutaneous edema is very rare. In this study, we report a case of CADM which presented with facial edema as the sole cutaneous manifestation and was later complicated by acute respiratory failure leading to mortality.
Case presentation
A 58-year-old woman presented with edema of the face that had developed approximately one year prior. It was not painful nor pruritic, but she felt it was more prominent on the left side. Courses of antibiotic therapy for a presumed diagnosis of cellulitis had not been effective, but glucocorticoids greatly improved the swelling, which relapsed rapidly with tapering. One week prior, as another course of glucocorticoids prescribed for a diagnosis of angioedema was tapered out, her facial edema relapsed, accompanied by tiny, pruritic vesicular lesions on the chin. Although she was evaluated in neurology and dental clinics, no specific diagnosis was made. She reported ‘dryness’ and ‘itchiness’ of the eyes, but not in the oral cavity.
On evaluation, there was bilateral swelling of the malar and temporal area of the face, involving the periorbital area and eyelid in the left side. On the chin, there was eczematoid vesicular eruption (Fig. 1a). There was no abnormal finding on the examination of the chest and abdomen. There was no edema or rash in the trunk or extremities. Neck flexion was preserved, and the power of the extremities’ motor function was evaluated as five on a scale of zero to five. On ophthalmologic examination, there was swelling of the left upper eyelid, and the anterior chamber was clear and deep in both eyes. Five-minute Schirmer test result was 6 mm in the right eye and 8 mm in the left eye (reference value < 5 mm for dry eye disease, but known to have low sensitivity in mild or moderate cases)[6]. Ocular staining score was 1 and 2 in the right and left eye, respectively (reference value ≥ 5 for classification of primary Sjögren’s syndrome)[7].
Fig. 1 Isolated facial edema and subclinical facial muscle involvement. At initial presentation there was bilateral swelling of the face and of the left eyelid, accompanied by eczematoid eruption on the chin (a). After approximately two weeks of medium-dose glucocorticoid therapy the edema and the lesions were completely resolved (b). However, combination therapy with either azathioprine, mycophenolate, or methotrexate was not successful in maintaining remission at a prednisolone dose lower than 15 mg per day. At the last relapse, there was marked aggravation of facial and eyelid edema (c). Gadolinium-enhanced MRI scan of the head shows diffuse edematous change with enhancement of bilateral masticator muscles (d, masseter muscle [yellow arrow] and lateral pterygoid muscle [black arrow]). There was also swelling of bilateral extra-ocular muscles and edematous change with fat infiltration in the subcutaneous tissues of the anterior scalp, periorbital area, buccal space, and anterior cervical fascia (not shown)
On the initial laboratory evaluation, there were no abnormalities, and the serum creatine phosphokinase (CPK) level was within normal range (Table 1). On serologic evaluation, antinuclear antibody was positive up to 1:160 in titer in homogeneous pattern, but anti-dsDNA Ab and anti-histone Ab was negative. Anti-SSA (> 240 U/mL) and anti-SSB (18 U/mL) antibodies were positive (fluorescent enzyme immunoassay, reference value < 7 U/mL for both); anti-RNP and anti-Smith Ab, negative. Anti-Jo1 antibody and anti-SRP antibody were negative. Anti-neutrophil cytoplasmic antibody was negative and IgG4 level was within normal range: 102 mg/dL (reference 30 ~ 201 mg/dL).
Table 1 Laboratory data
Variable Reference range At initial presentation At the second admission
WBC 4.0 ~ 10.0 × 109/L 5.2 2.84
RBC 4.2 ~ 5.4 × 1012/L 4.23 4.38
Hgb 12.0 ~ 16.0 g/dL 12.4 13.7
Platelet 140 ~ 440 × 109/L 230 166
Differential Count
Neutrophil 40 ~ 80 % 57.8 66.8
Lymphocyte 15 ~ 50 % 30.2 20.8
Monocyte 2 ~ 11 % 7.9 9.2
Eosinophil 0 ~ 7 % 3.5 2.8
Basophil 0 ~ 1 % 0.6 0.4
ESR ~ 120 mm 14 21
Total Protein 6.0 ~ 8.0 g/dl 7.4 7.1
Albumin 3.5 ~ 5.2 g/dl 4.3 4.1
Total Bilirubin ~ 1.2 mg/dl 0.64 1.01
AST 7 ~ 38 U/L 36 50
ALT 4 ~ 43 U/L 32 69
ALP 36 ~ 104 U/L 79 58
Glucose 70 ~ 110 mg/dl 84 109
Total Cholesterol ~ 200 mg/dl 171 204
BUN 6.0 ~ 20.0 mg/dl 16 18.6
Creatinine 0.6 ~ 1.2 mg/dl 0.79 0.82
Direct Bilirubin ~ 0.3 mg/dl 0.19 0.24
LDH ~ 250 IU/L 269 424
CPK 50 ~ 200 U/L 182 317
Uric acid 3.0 ~ 5.5 mg/dl 3.5 3.4
CRP ~ 0.30 mg/dL 0.05 0.68
WBC white blood cell, RBC red blood cell, ESR erythrocyte sedimentation rate, AST aspartate aminotransferase, ALT alanine aminotransferase, ALP alkaline phosphatase, BUN blood urea nitrogen, LDH lactase dehydrogenase, CPK creatine phosphokinase, CRP C-reactive protein
On MRI, there was a diffuse edematous change in the bilateral masticator and extra-ocular muscles, accompanied by subcutaneous fat infiltration in the buccal and periorbital spaces. There was inhomogeneous enhancement of bilateral parotid glands. On PET-CT scan there was diffuse F-18-FDG uptake in the periorbital, frontalis, temporalis, and masseter muscles and the buccal and submandibular spaces without any increased uptake in the extremities or internal organs.
The Head and Neck Surgery and Radiology departments opined that a biopsy of the muscles would entail risk of complications such as bleeding and injury to the muscles. After a discussion with the patient regarding undergoing a muscle biopsy, a presumptive clinical diagnosis of an overlap syndrome of Sjogren’s syndrome with myositis was made and treatment with a medium-dose glucocorticoid (prednisolone 30 mg/day) begun; based on reports of orbital involvement, a good response to therapy, and benign prognosis in myositis associated with Sjogren’s syndrome[8–10]. On 16th day of treatment, the facial swelling was assessed as having completely resolved (Fig. 1b); however, the facial edema relapsed during subsequent days when glucocorticoid doses were lowered to less than 15 mg/day. Combination therapy with azathioprine, mycophenolate, or methotrexate for eight months was not effective in maintaining remission at acceptable doses of glucocorticoid, and the swelling aggravated considerably with the final relapse.
The patient finally agreed to further evaluation and was admitted to the hospital. On examination, there was aggravation of the facial edema (Fig. 1c). There was swelling of the right ankle, without tenderness. Neck flexion was preserved and motor power of extremities was assessed as five on a scale of zero to five. On laboratory evaluation, there was mild elevation of liver transaminases and CPK (Table 1). Serum aldolase was 7.9 U/L (reference < 7.6 U/L). On MRI of the head, there was aggravation of the inflammation (Fig. 1d). On ultrasonography of the right ankle, there was subcutaneous edema without evidence of synovitis. A series of evaluations to screen for malignancy including tumor makers (CA19-9, CEA, and CA125), esophagogastroduodenoscopy, colonoscopy, and mammography did not reveal abnormal findings.
A US-guided core-needle biopsy with an 18-gauge needle was performed in the right masseter muscle. Two pieces of tiny muscle tissue, measuring up to 0.5 × 0.1 cm, were obtained. On pathologic examination, there was moderate size variation of the myofibers, and endomysial and perimysial fibrosis. There was patchy CD4 + T cell-dominant lymphoplasmacytic infiltration in the stroma and atrophy of the myofibers, mainly at the periphery of the fascicles, being consistent with perifascicular atrophy. Necrosis of the myofibers was not prominent (Fig. 2). Based on these findings, a diagnosis of clinically amyopathic dermatomyositis was made.
Fig. 2 Biopsy specimens from the right masseter muscle. Hematoxylin and eosin staining shows moderate size variation of the myofibers and endomysial and perimysial fibrosis (white arrow). There is atrophy of the myofibers, mainly at the periphery of the fascicles (black arrow), which is consistent with perifascicular atrophy (a). Patchy lymphoplasmacytic infiltration (white arrow) is noted in the stroma (b), which consists of predominantly more CD4-positive cells (c) than CD8-positive cells (d) in immunohistochemical staining. All figures are at 200-fold magnification
Therapy with gamma-globulin (IVIG, 2.1 g/kg per month) in combination with prednisolone 30 mg/day was initiated, and after the first cycle the facial edema had resolved completely. However, when the dose of prednisolone was decreased to 15 mg/day, she made an earlier visit to the clinic with a relapse of the facial edema within six days. By the fourth cycle of IVIG, sustained remission could not be achieved. A course of rituximab (1.0 g twice, a week apart) in combination with methylprednisolone 40 mg/day was started. In the sixth week of rituximab therapy, when glucocorticoid dose was decreased to methylprednisolone 32 mg/day, she presented to the emergency room with altered mentality that began one day prior. On presentation, there was a fever of 38.7 °C, and the patient began mechanical ventilation immediately for hypoxemic respiratory failure. On chest X-ray, there was diffuse consolidation in both lung fields (Fig. 3b). On high-resolution CT, there was diffuse consolidation in the dependent portion of the lungs and diffuse ground glass opacity with relative sparing of the base of the lungs (Fig. 3c, d). The next day, the patient underwent bronchoscopy with bronchoalveolar lavage. The total cell count was 12 × 106 cells in 9 mL of fluid. Differential data of each cell type was as follows: macrophage 8 %, neutrophil 83 %, and lymphocyte 9 %. There was no bacteria isolated from the respiratory specimen, and a polymerase chain reaction (PCR) test for respiratory viruses including adenovirus, influenza virus, parainfluenza virus, and respiratory syncytial virus was negative. Pneumocystis jirovecii PCR and Gomori methenamine silver (GMS) staining were positive, and the patient began treatment with trimethoprim-sulfamethoxazole and glucocorticoids; but her hypoxemic respiratory failure progressed, and veno-venous extracorporeal (ECMO) membrane oxygenation was begun three days later. Given the lack of response to antibiotics therapy, glucocorticoid pulse and IV cyclosporine was started in consideration of rapidly progressive interstitial lung disease (RP-ILD). Over the next three weeks, despite the addition of polymyxin B-immobilized fiber column direct hemoperfusion (PMX-DHP)[11], there was no improvement in her hypoxemic respiratory failure, and according to the family’s will, the ECMO was weaned. On that day, she expired from respiratory failure.
Fig. 3 Chest radiographic images before and at the presentation of acute respiratory failure. Chest postero-anterior radiography taken about one month after initiating rituximab therapy shows no clear haziness or infiltration in both lung fields (a). At the presentation of acute respiratory failure with altered mentality (in the sixth week after starting rituximab) there was diffuse bilateral infiltration in both lung fields with relative sparing of both lower lung fields (b). Axial high-resolution computed tomography images show diffuse ground glass opacity in both upper lungs with consolidation in dependent areas (c); The lung base is relatively spared (d)
Discussion and Conclusions
This case, which posed significant diagnostic and therapeutic challenges, leaves important lessons for practice and research. First, isolated localized edema may be the initial manifestation of CADM. Such a case is considered very rare; we could find only one case reported in sufficient detail for us to verify the absence of muscle disease and other cutaneous manifestations, the prognosis of which was not known[12]. Second, although the patient presented initially with mild glucocorticoid-responsive facial edema, her course showed increasing extent of subcutaneous edema, decreasing response to immunomodulating therapy, and acute and severe involvement of the lungs leading to death. This suggests the prognosis cannot be predicted by the initially mild clinical manifestation alone.
Severe respiratory complications in idiopathic inflammatory myopathies such as DM pose considerable challenges to treatment, and the prognosis is poor[13, 14]. Differential diagnoses include cardiac complications, respiratory muscle weakness, drug hypersensitivity, RP-ILD, and severe and opportunistic infections[15, 16]. In many cases, it is difficult to arrive at a specific diagnosis, and there is a therapeutic dilemma of treating a severe autoimmune inflammation and a difficult-to-treat infection at the same time. Also in this case, there are a couple of explanations for the acute respiratory disease. First, the possibility of Pneumocystis pneumonia (PCP) should be considered. Prolonged glucocorticoid therapy is one of the risk factors for PCP in patients undergoing immunomodulating therapy for systemic autoimmune rheumatic diseases, and the patient was not receiving prophylaxis for it because of thrombocytopenia (< 50,000/mm3). Radiographic findings of acutely developed consolidation and ground glass opacity with relative sparing of the lung base is suggestive of PCP, and PCR and GMS staining were positive. In addition, even with appropriate treatment, mortality in fulminant PCP in non-HIV immunocompromised patients is high; in a recent study, the mortality rate in idiopathic inflammatory myopathy (including CADM) patients admitted to ICUs was 79.4 %, and PCP comprised approximately 20 % of the admissions[13]. Second, we believe the possibility of RP-ILD should be considered. From the early 2000s, associations between CADM and RP-ILD with poor prognosis were reported in Northeast Asia, including Korea, with mortality reaching approximately 50 %[17–19]. Later studies identified an association between anti-melanoma differentiation-associated protein 5 (MDA5) antibody and RP-ILD[20] [21], both of which are more common in CADM than in DM[22], and in Asians compared with Caucasians[21]. Recent studies report initial combination immunosuppressive therapies improved survival in RP-ILD in CADM[23], and that in the case of refractories a rescue therapy with tofacitinib may improve the outcome[24, 25]. Although we could not evaluate the presence of anti-MDA5 Ab in this case, which is a limitation of this study, rapidly progressive ILD was a possibility in the differential diagnosis of acute respiratory failure which did not respond to antibiotic therapy. Third, rituximab-induced lung disease could be considered. The patient developed acute respiratory symptoms five weeks and one day after the last rituximab infusion. This was in the period when late-onset respiratory illness may develop after rituximab infusion. However, late-onset rituximab-induced respiratory illness is less frequent than delayed-onset illness, shows a chronic course over weeks or months, and responds well to glucocorticoid therapy[26].
In conclusion, this case showed that CADM can initially manifest as a localized subcutaneous edema as the sole cutaneous manifestation but follow a progressive, refractory, and fatal course with major organ involvement, especially involving the lungs. A specific auto-antibody pattern may better predict the prognosis. Identification of the specific antibody profile and prompt initiation of therapy with proven efficacy may improve the outcome.
Authors’ contributions.
DHL analyzed clinical data and prepared the manuscript. YMK performed pathologic examination of the muscle biopsy samples and wrote the pathologic results. JHR performed the radiologic examination and muscle biopsy and contributed to writing. JHL, CSP, and SHK participated in critical care of the patient and contributed to writing. SL planned the study and performed analysis of data and literature. All authors read and approved the final manuscript.
Publisher’s Note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
Acknowledgements
Not applicable.
Authors' contributions
DHL analyzed clinical data and prepared the manuscript. YMK performed pathologic examination of the muscle biopsy samples and wrote the pathologic results. JHR performed the radiologic examination and muscle biopsy and contributed to writing. JHL, CSP, and SHK participated in critical care of the patient and contributed to writing. SL planned the study and performed analysis of data and literature. All authors read and approved the final manuscript.
Funding
Not applicable.
Availability of data and materials
Not applicable.
Ethics approval and consent to participate
This study was approved by the institutional review board of Haeundae Paik hospital (IRB file number: HPIRB 2019-08-016-001).
Consent for publication
Written informed consent was obtained from the patient, including the use of photographs of the face.
Competing interests
The authors declare that they have no competing interests. | 2.1 G/KG PER MONTH | DrugDosageText | CC BY | 33509162 | 18,862,926 | 2021-01-28 |
What was the outcome of reaction 'Acute respiratory failure'? | Clinically amyopathic dermatomyositis presenting with isolated facial edema complicated by acute respiratory failure: a case report.
BACKGROUND
In clinically amyopathic dermatomyositis, the hallmark cutaneous manifestations are the key to diagnosis. We report a case of clinically amyopathic dermatomyositis which presented with facial edema as the sole cutaneous manifestation and was later complicated by acute respiratory failure leading to death.
METHODS
A 58-year-old woman presented with edema of the face that had developed approximately one year ago. There was no weakness in the extremities, and the serum creatine kinase level was within normal range. On MRI, there was diffuse edematous change in the bilateral masticator and extra-ocular muscles, accompanied by subcutaneous fat infiltration in the face. A shared decision was made to defer muscle biopsy in the facial muscles. The facial swelling almost resolved with medium-dose glucocorticoid therapy but relapsed in days at glucocorticoid doses lower than 15 mg/day. Combination therapy with either azathioprine, mycophenolate, or methotrexate was not successful in maintaining clinical remission, and the swelling became more severe after relapses. A US-guided core-needle biopsy was subsequently performed in the right masseter muscle. On pathologic examination, there was a patchy CD4 + T cell-dominant lymphoplasmacytic infiltration in the stroma, necrosis of the myofibrils and prominent perifascicular atrophy. Based on those findings, a diagnosis of clinically amyopathic dermatomyositis was made. Therapy with gamma-globulin was not effective in maintaining remission. In the sixth week after starting rituximab, she presented to emergency room with altered mental state from acute respiratory failure. Despite treatment with antibiotics, glucocorticoid pulse, cyclosporin, and polymyxin B-immobilized fiber column direct hemoperfusion, she died three weeks later from persistent hypoxemic respiratory failure.
CONCLUSIONS
This case showed the full spectrum and severity of internal organ involvement of dermatomyositis, although the patient presented exclusively with subcutaneous edema limited to the head. The prognosis may be more closely associated with a specific auto-antibody profile than the benign-looking initial clinical manifestation. Close follow-up of lung involvement with prophylactic treatment for Pneumocystis pneumonia and prompt implementation of emerging therapeutic regimens may improve the outcome.
Background
Even before the classification of dermatomyositis (DM) was defined by Bohan and Peter in 1975, it was well known that there was a subgroup of patients who did not have muscle disease, regarded as amyopathic dermatomyositis (ADM)[1]. Studies have shown that there is evidence of subclinical muscle disease in MRI imaging and muscle biopsy in ADM leading to the concept of clinically amyopathic dermatomyositis (CADM), which is defined as absence of clinical muscle disease on physical examination and muscle enzyme analysis for at least six months[2]. In CADM, which represents about 11–20 % of dermatomyositis (DM)[3, 4], the hallmark cutaneous manifestations such as Heliotrope rash, Gottron’s papules, and Gottron’s sign are the key to diagnosis.
There has been a report that suggested that subcutaneous edema is a cutaneous manifestation of DM because it can be the only skin lesion at presentation[5]. In the case series, edematous DM comprised 6 % (5/86) of a DM cohort. In the muscle biopsies of the five cases of edematous DM, there were frequent microinfarctions, which were considered to be induced by vasculitis producing micro-ischemia. In the reported five cases and review of 19 reported cases, there were six cases (3/5 and 3/19, respectively) in which subcutaneous edema was the sole cutaneous manifestation, but all had clinical muscle disease, suggesting that CADM presenting exclusively with subcutaneous edema is very rare. In this study, we report a case of CADM which presented with facial edema as the sole cutaneous manifestation and was later complicated by acute respiratory failure leading to mortality.
Case presentation
A 58-year-old woman presented with edema of the face that had developed approximately one year prior. It was not painful nor pruritic, but she felt it was more prominent on the left side. Courses of antibiotic therapy for a presumed diagnosis of cellulitis had not been effective, but glucocorticoids greatly improved the swelling, which relapsed rapidly with tapering. One week prior, as another course of glucocorticoids prescribed for a diagnosis of angioedema was tapered out, her facial edema relapsed, accompanied by tiny, pruritic vesicular lesions on the chin. Although she was evaluated in neurology and dental clinics, no specific diagnosis was made. She reported ‘dryness’ and ‘itchiness’ of the eyes, but not in the oral cavity.
On evaluation, there was bilateral swelling of the malar and temporal area of the face, involving the periorbital area and eyelid in the left side. On the chin, there was eczematoid vesicular eruption (Fig. 1a). There was no abnormal finding on the examination of the chest and abdomen. There was no edema or rash in the trunk or extremities. Neck flexion was preserved, and the power of the extremities’ motor function was evaluated as five on a scale of zero to five. On ophthalmologic examination, there was swelling of the left upper eyelid, and the anterior chamber was clear and deep in both eyes. Five-minute Schirmer test result was 6 mm in the right eye and 8 mm in the left eye (reference value < 5 mm for dry eye disease, but known to have low sensitivity in mild or moderate cases)[6]. Ocular staining score was 1 and 2 in the right and left eye, respectively (reference value ≥ 5 for classification of primary Sjögren’s syndrome)[7].
Fig. 1 Isolated facial edema and subclinical facial muscle involvement. At initial presentation there was bilateral swelling of the face and of the left eyelid, accompanied by eczematoid eruption on the chin (a). After approximately two weeks of medium-dose glucocorticoid therapy the edema and the lesions were completely resolved (b). However, combination therapy with either azathioprine, mycophenolate, or methotrexate was not successful in maintaining remission at a prednisolone dose lower than 15 mg per day. At the last relapse, there was marked aggravation of facial and eyelid edema (c). Gadolinium-enhanced MRI scan of the head shows diffuse edematous change with enhancement of bilateral masticator muscles (d, masseter muscle [yellow arrow] and lateral pterygoid muscle [black arrow]). There was also swelling of bilateral extra-ocular muscles and edematous change with fat infiltration in the subcutaneous tissues of the anterior scalp, periorbital area, buccal space, and anterior cervical fascia (not shown)
On the initial laboratory evaluation, there were no abnormalities, and the serum creatine phosphokinase (CPK) level was within normal range (Table 1). On serologic evaluation, antinuclear antibody was positive up to 1:160 in titer in homogeneous pattern, but anti-dsDNA Ab and anti-histone Ab was negative. Anti-SSA (> 240 U/mL) and anti-SSB (18 U/mL) antibodies were positive (fluorescent enzyme immunoassay, reference value < 7 U/mL for both); anti-RNP and anti-Smith Ab, negative. Anti-Jo1 antibody and anti-SRP antibody were negative. Anti-neutrophil cytoplasmic antibody was negative and IgG4 level was within normal range: 102 mg/dL (reference 30 ~ 201 mg/dL).
Table 1 Laboratory data
Variable Reference range At initial presentation At the second admission
WBC 4.0 ~ 10.0 × 109/L 5.2 2.84
RBC 4.2 ~ 5.4 × 1012/L 4.23 4.38
Hgb 12.0 ~ 16.0 g/dL 12.4 13.7
Platelet 140 ~ 440 × 109/L 230 166
Differential Count
Neutrophil 40 ~ 80 % 57.8 66.8
Lymphocyte 15 ~ 50 % 30.2 20.8
Monocyte 2 ~ 11 % 7.9 9.2
Eosinophil 0 ~ 7 % 3.5 2.8
Basophil 0 ~ 1 % 0.6 0.4
ESR ~ 120 mm 14 21
Total Protein 6.0 ~ 8.0 g/dl 7.4 7.1
Albumin 3.5 ~ 5.2 g/dl 4.3 4.1
Total Bilirubin ~ 1.2 mg/dl 0.64 1.01
AST 7 ~ 38 U/L 36 50
ALT 4 ~ 43 U/L 32 69
ALP 36 ~ 104 U/L 79 58
Glucose 70 ~ 110 mg/dl 84 109
Total Cholesterol ~ 200 mg/dl 171 204
BUN 6.0 ~ 20.0 mg/dl 16 18.6
Creatinine 0.6 ~ 1.2 mg/dl 0.79 0.82
Direct Bilirubin ~ 0.3 mg/dl 0.19 0.24
LDH ~ 250 IU/L 269 424
CPK 50 ~ 200 U/L 182 317
Uric acid 3.0 ~ 5.5 mg/dl 3.5 3.4
CRP ~ 0.30 mg/dL 0.05 0.68
WBC white blood cell, RBC red blood cell, ESR erythrocyte sedimentation rate, AST aspartate aminotransferase, ALT alanine aminotransferase, ALP alkaline phosphatase, BUN blood urea nitrogen, LDH lactase dehydrogenase, CPK creatine phosphokinase, CRP C-reactive protein
On MRI, there was a diffuse edematous change in the bilateral masticator and extra-ocular muscles, accompanied by subcutaneous fat infiltration in the buccal and periorbital spaces. There was inhomogeneous enhancement of bilateral parotid glands. On PET-CT scan there was diffuse F-18-FDG uptake in the periorbital, frontalis, temporalis, and masseter muscles and the buccal and submandibular spaces without any increased uptake in the extremities or internal organs.
The Head and Neck Surgery and Radiology departments opined that a biopsy of the muscles would entail risk of complications such as bleeding and injury to the muscles. After a discussion with the patient regarding undergoing a muscle biopsy, a presumptive clinical diagnosis of an overlap syndrome of Sjogren’s syndrome with myositis was made and treatment with a medium-dose glucocorticoid (prednisolone 30 mg/day) begun; based on reports of orbital involvement, a good response to therapy, and benign prognosis in myositis associated with Sjogren’s syndrome[8–10]. On 16th day of treatment, the facial swelling was assessed as having completely resolved (Fig. 1b); however, the facial edema relapsed during subsequent days when glucocorticoid doses were lowered to less than 15 mg/day. Combination therapy with azathioprine, mycophenolate, or methotrexate for eight months was not effective in maintaining remission at acceptable doses of glucocorticoid, and the swelling aggravated considerably with the final relapse.
The patient finally agreed to further evaluation and was admitted to the hospital. On examination, there was aggravation of the facial edema (Fig. 1c). There was swelling of the right ankle, without tenderness. Neck flexion was preserved and motor power of extremities was assessed as five on a scale of zero to five. On laboratory evaluation, there was mild elevation of liver transaminases and CPK (Table 1). Serum aldolase was 7.9 U/L (reference < 7.6 U/L). On MRI of the head, there was aggravation of the inflammation (Fig. 1d). On ultrasonography of the right ankle, there was subcutaneous edema without evidence of synovitis. A series of evaluations to screen for malignancy including tumor makers (CA19-9, CEA, and CA125), esophagogastroduodenoscopy, colonoscopy, and mammography did not reveal abnormal findings.
A US-guided core-needle biopsy with an 18-gauge needle was performed in the right masseter muscle. Two pieces of tiny muscle tissue, measuring up to 0.5 × 0.1 cm, were obtained. On pathologic examination, there was moderate size variation of the myofibers, and endomysial and perimysial fibrosis. There was patchy CD4 + T cell-dominant lymphoplasmacytic infiltration in the stroma and atrophy of the myofibers, mainly at the periphery of the fascicles, being consistent with perifascicular atrophy. Necrosis of the myofibers was not prominent (Fig. 2). Based on these findings, a diagnosis of clinically amyopathic dermatomyositis was made.
Fig. 2 Biopsy specimens from the right masseter muscle. Hematoxylin and eosin staining shows moderate size variation of the myofibers and endomysial and perimysial fibrosis (white arrow). There is atrophy of the myofibers, mainly at the periphery of the fascicles (black arrow), which is consistent with perifascicular atrophy (a). Patchy lymphoplasmacytic infiltration (white arrow) is noted in the stroma (b), which consists of predominantly more CD4-positive cells (c) than CD8-positive cells (d) in immunohistochemical staining. All figures are at 200-fold magnification
Therapy with gamma-globulin (IVIG, 2.1 g/kg per month) in combination with prednisolone 30 mg/day was initiated, and after the first cycle the facial edema had resolved completely. However, when the dose of prednisolone was decreased to 15 mg/day, she made an earlier visit to the clinic with a relapse of the facial edema within six days. By the fourth cycle of IVIG, sustained remission could not be achieved. A course of rituximab (1.0 g twice, a week apart) in combination with methylprednisolone 40 mg/day was started. In the sixth week of rituximab therapy, when glucocorticoid dose was decreased to methylprednisolone 32 mg/day, she presented to the emergency room with altered mentality that began one day prior. On presentation, there was a fever of 38.7 °C, and the patient began mechanical ventilation immediately for hypoxemic respiratory failure. On chest X-ray, there was diffuse consolidation in both lung fields (Fig. 3b). On high-resolution CT, there was diffuse consolidation in the dependent portion of the lungs and diffuse ground glass opacity with relative sparing of the base of the lungs (Fig. 3c, d). The next day, the patient underwent bronchoscopy with bronchoalveolar lavage. The total cell count was 12 × 106 cells in 9 mL of fluid. Differential data of each cell type was as follows: macrophage 8 %, neutrophil 83 %, and lymphocyte 9 %. There was no bacteria isolated from the respiratory specimen, and a polymerase chain reaction (PCR) test for respiratory viruses including adenovirus, influenza virus, parainfluenza virus, and respiratory syncytial virus was negative. Pneumocystis jirovecii PCR and Gomori methenamine silver (GMS) staining were positive, and the patient began treatment with trimethoprim-sulfamethoxazole and glucocorticoids; but her hypoxemic respiratory failure progressed, and veno-venous extracorporeal (ECMO) membrane oxygenation was begun three days later. Given the lack of response to antibiotics therapy, glucocorticoid pulse and IV cyclosporine was started in consideration of rapidly progressive interstitial lung disease (RP-ILD). Over the next three weeks, despite the addition of polymyxin B-immobilized fiber column direct hemoperfusion (PMX-DHP)[11], there was no improvement in her hypoxemic respiratory failure, and according to the family’s will, the ECMO was weaned. On that day, she expired from respiratory failure.
Fig. 3 Chest radiographic images before and at the presentation of acute respiratory failure. Chest postero-anterior radiography taken about one month after initiating rituximab therapy shows no clear haziness or infiltration in both lung fields (a). At the presentation of acute respiratory failure with altered mentality (in the sixth week after starting rituximab) there was diffuse bilateral infiltration in both lung fields with relative sparing of both lower lung fields (b). Axial high-resolution computed tomography images show diffuse ground glass opacity in both upper lungs with consolidation in dependent areas (c); The lung base is relatively spared (d)
Discussion and Conclusions
This case, which posed significant diagnostic and therapeutic challenges, leaves important lessons for practice and research. First, isolated localized edema may be the initial manifestation of CADM. Such a case is considered very rare; we could find only one case reported in sufficient detail for us to verify the absence of muscle disease and other cutaneous manifestations, the prognosis of which was not known[12]. Second, although the patient presented initially with mild glucocorticoid-responsive facial edema, her course showed increasing extent of subcutaneous edema, decreasing response to immunomodulating therapy, and acute and severe involvement of the lungs leading to death. This suggests the prognosis cannot be predicted by the initially mild clinical manifestation alone.
Severe respiratory complications in idiopathic inflammatory myopathies such as DM pose considerable challenges to treatment, and the prognosis is poor[13, 14]. Differential diagnoses include cardiac complications, respiratory muscle weakness, drug hypersensitivity, RP-ILD, and severe and opportunistic infections[15, 16]. In many cases, it is difficult to arrive at a specific diagnosis, and there is a therapeutic dilemma of treating a severe autoimmune inflammation and a difficult-to-treat infection at the same time. Also in this case, there are a couple of explanations for the acute respiratory disease. First, the possibility of Pneumocystis pneumonia (PCP) should be considered. Prolonged glucocorticoid therapy is one of the risk factors for PCP in patients undergoing immunomodulating therapy for systemic autoimmune rheumatic diseases, and the patient was not receiving prophylaxis for it because of thrombocytopenia (< 50,000/mm3). Radiographic findings of acutely developed consolidation and ground glass opacity with relative sparing of the lung base is suggestive of PCP, and PCR and GMS staining were positive. In addition, even with appropriate treatment, mortality in fulminant PCP in non-HIV immunocompromised patients is high; in a recent study, the mortality rate in idiopathic inflammatory myopathy (including CADM) patients admitted to ICUs was 79.4 %, and PCP comprised approximately 20 % of the admissions[13]. Second, we believe the possibility of RP-ILD should be considered. From the early 2000s, associations between CADM and RP-ILD with poor prognosis were reported in Northeast Asia, including Korea, with mortality reaching approximately 50 %[17–19]. Later studies identified an association between anti-melanoma differentiation-associated protein 5 (MDA5) antibody and RP-ILD[20] [21], both of which are more common in CADM than in DM[22], and in Asians compared with Caucasians[21]. Recent studies report initial combination immunosuppressive therapies improved survival in RP-ILD in CADM[23], and that in the case of refractories a rescue therapy with tofacitinib may improve the outcome[24, 25]. Although we could not evaluate the presence of anti-MDA5 Ab in this case, which is a limitation of this study, rapidly progressive ILD was a possibility in the differential diagnosis of acute respiratory failure which did not respond to antibiotic therapy. Third, rituximab-induced lung disease could be considered. The patient developed acute respiratory symptoms five weeks and one day after the last rituximab infusion. This was in the period when late-onset respiratory illness may develop after rituximab infusion. However, late-onset rituximab-induced respiratory illness is less frequent than delayed-onset illness, shows a chronic course over weeks or months, and responds well to glucocorticoid therapy[26].
In conclusion, this case showed that CADM can initially manifest as a localized subcutaneous edema as the sole cutaneous manifestation but follow a progressive, refractory, and fatal course with major organ involvement, especially involving the lungs. A specific auto-antibody pattern may better predict the prognosis. Identification of the specific antibody profile and prompt initiation of therapy with proven efficacy may improve the outcome.
Authors’ contributions.
DHL analyzed clinical data and prepared the manuscript. YMK performed pathologic examination of the muscle biopsy samples and wrote the pathologic results. JHR performed the radiologic examination and muscle biopsy and contributed to writing. JHL, CSP, and SHK participated in critical care of the patient and contributed to writing. SL planned the study and performed analysis of data and literature. All authors read and approved the final manuscript.
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Acknowledgements
Not applicable.
Authors' contributions
DHL analyzed clinical data and prepared the manuscript. YMK performed pathologic examination of the muscle biopsy samples and wrote the pathologic results. JHR performed the radiologic examination and muscle biopsy and contributed to writing. JHL, CSP, and SHK participated in critical care of the patient and contributed to writing. SL planned the study and performed analysis of data and literature. All authors read and approved the final manuscript.
Funding
Not applicable.
Availability of data and materials
Not applicable.
Ethics approval and consent to participate
This study was approved by the institutional review board of Haeundae Paik hospital (IRB file number: HPIRB 2019-08-016-001).
Consent for publication
Written informed consent was obtained from the patient, including the use of photographs of the face.
Competing interests
The authors declare that they have no competing interests. | Fatal | ReactionOutcome | CC BY | 33509162 | 18,862,926 | 2021-01-28 |
What was the outcome of reaction 'Disease progression'? | Clinically amyopathic dermatomyositis presenting with isolated facial edema complicated by acute respiratory failure: a case report.
BACKGROUND
In clinically amyopathic dermatomyositis, the hallmark cutaneous manifestations are the key to diagnosis. We report a case of clinically amyopathic dermatomyositis which presented with facial edema as the sole cutaneous manifestation and was later complicated by acute respiratory failure leading to death.
METHODS
A 58-year-old woman presented with edema of the face that had developed approximately one year ago. There was no weakness in the extremities, and the serum creatine kinase level was within normal range. On MRI, there was diffuse edematous change in the bilateral masticator and extra-ocular muscles, accompanied by subcutaneous fat infiltration in the face. A shared decision was made to defer muscle biopsy in the facial muscles. The facial swelling almost resolved with medium-dose glucocorticoid therapy but relapsed in days at glucocorticoid doses lower than 15 mg/day. Combination therapy with either azathioprine, mycophenolate, or methotrexate was not successful in maintaining clinical remission, and the swelling became more severe after relapses. A US-guided core-needle biopsy was subsequently performed in the right masseter muscle. On pathologic examination, there was a patchy CD4 + T cell-dominant lymphoplasmacytic infiltration in the stroma, necrosis of the myofibrils and prominent perifascicular atrophy. Based on those findings, a diagnosis of clinically amyopathic dermatomyositis was made. Therapy with gamma-globulin was not effective in maintaining remission. In the sixth week after starting rituximab, she presented to emergency room with altered mental state from acute respiratory failure. Despite treatment with antibiotics, glucocorticoid pulse, cyclosporin, and polymyxin B-immobilized fiber column direct hemoperfusion, she died three weeks later from persistent hypoxemic respiratory failure.
CONCLUSIONS
This case showed the full spectrum and severity of internal organ involvement of dermatomyositis, although the patient presented exclusively with subcutaneous edema limited to the head. The prognosis may be more closely associated with a specific auto-antibody profile than the benign-looking initial clinical manifestation. Close follow-up of lung involvement with prophylactic treatment for Pneumocystis pneumonia and prompt implementation of emerging therapeutic regimens may improve the outcome.
Background
Even before the classification of dermatomyositis (DM) was defined by Bohan and Peter in 1975, it was well known that there was a subgroup of patients who did not have muscle disease, regarded as amyopathic dermatomyositis (ADM)[1]. Studies have shown that there is evidence of subclinical muscle disease in MRI imaging and muscle biopsy in ADM leading to the concept of clinically amyopathic dermatomyositis (CADM), which is defined as absence of clinical muscle disease on physical examination and muscle enzyme analysis for at least six months[2]. In CADM, which represents about 11–20 % of dermatomyositis (DM)[3, 4], the hallmark cutaneous manifestations such as Heliotrope rash, Gottron’s papules, and Gottron’s sign are the key to diagnosis.
There has been a report that suggested that subcutaneous edema is a cutaneous manifestation of DM because it can be the only skin lesion at presentation[5]. In the case series, edematous DM comprised 6 % (5/86) of a DM cohort. In the muscle biopsies of the five cases of edematous DM, there were frequent microinfarctions, which were considered to be induced by vasculitis producing micro-ischemia. In the reported five cases and review of 19 reported cases, there were six cases (3/5 and 3/19, respectively) in which subcutaneous edema was the sole cutaneous manifestation, but all had clinical muscle disease, suggesting that CADM presenting exclusively with subcutaneous edema is very rare. In this study, we report a case of CADM which presented with facial edema as the sole cutaneous manifestation and was later complicated by acute respiratory failure leading to mortality.
Case presentation
A 58-year-old woman presented with edema of the face that had developed approximately one year prior. It was not painful nor pruritic, but she felt it was more prominent on the left side. Courses of antibiotic therapy for a presumed diagnosis of cellulitis had not been effective, but glucocorticoids greatly improved the swelling, which relapsed rapidly with tapering. One week prior, as another course of glucocorticoids prescribed for a diagnosis of angioedema was tapered out, her facial edema relapsed, accompanied by tiny, pruritic vesicular lesions on the chin. Although she was evaluated in neurology and dental clinics, no specific diagnosis was made. She reported ‘dryness’ and ‘itchiness’ of the eyes, but not in the oral cavity.
On evaluation, there was bilateral swelling of the malar and temporal area of the face, involving the periorbital area and eyelid in the left side. On the chin, there was eczematoid vesicular eruption (Fig. 1a). There was no abnormal finding on the examination of the chest and abdomen. There was no edema or rash in the trunk or extremities. Neck flexion was preserved, and the power of the extremities’ motor function was evaluated as five on a scale of zero to five. On ophthalmologic examination, there was swelling of the left upper eyelid, and the anterior chamber was clear and deep in both eyes. Five-minute Schirmer test result was 6 mm in the right eye and 8 mm in the left eye (reference value < 5 mm for dry eye disease, but known to have low sensitivity in mild or moderate cases)[6]. Ocular staining score was 1 and 2 in the right and left eye, respectively (reference value ≥ 5 for classification of primary Sjögren’s syndrome)[7].
Fig. 1 Isolated facial edema and subclinical facial muscle involvement. At initial presentation there was bilateral swelling of the face and of the left eyelid, accompanied by eczematoid eruption on the chin (a). After approximately two weeks of medium-dose glucocorticoid therapy the edema and the lesions were completely resolved (b). However, combination therapy with either azathioprine, mycophenolate, or methotrexate was not successful in maintaining remission at a prednisolone dose lower than 15 mg per day. At the last relapse, there was marked aggravation of facial and eyelid edema (c). Gadolinium-enhanced MRI scan of the head shows diffuse edematous change with enhancement of bilateral masticator muscles (d, masseter muscle [yellow arrow] and lateral pterygoid muscle [black arrow]). There was also swelling of bilateral extra-ocular muscles and edematous change with fat infiltration in the subcutaneous tissues of the anterior scalp, periorbital area, buccal space, and anterior cervical fascia (not shown)
On the initial laboratory evaluation, there were no abnormalities, and the serum creatine phosphokinase (CPK) level was within normal range (Table 1). On serologic evaluation, antinuclear antibody was positive up to 1:160 in titer in homogeneous pattern, but anti-dsDNA Ab and anti-histone Ab was negative. Anti-SSA (> 240 U/mL) and anti-SSB (18 U/mL) antibodies were positive (fluorescent enzyme immunoassay, reference value < 7 U/mL for both); anti-RNP and anti-Smith Ab, negative. Anti-Jo1 antibody and anti-SRP antibody were negative. Anti-neutrophil cytoplasmic antibody was negative and IgG4 level was within normal range: 102 mg/dL (reference 30 ~ 201 mg/dL).
Table 1 Laboratory data
Variable Reference range At initial presentation At the second admission
WBC 4.0 ~ 10.0 × 109/L 5.2 2.84
RBC 4.2 ~ 5.4 × 1012/L 4.23 4.38
Hgb 12.0 ~ 16.0 g/dL 12.4 13.7
Platelet 140 ~ 440 × 109/L 230 166
Differential Count
Neutrophil 40 ~ 80 % 57.8 66.8
Lymphocyte 15 ~ 50 % 30.2 20.8
Monocyte 2 ~ 11 % 7.9 9.2
Eosinophil 0 ~ 7 % 3.5 2.8
Basophil 0 ~ 1 % 0.6 0.4
ESR ~ 120 mm 14 21
Total Protein 6.0 ~ 8.0 g/dl 7.4 7.1
Albumin 3.5 ~ 5.2 g/dl 4.3 4.1
Total Bilirubin ~ 1.2 mg/dl 0.64 1.01
AST 7 ~ 38 U/L 36 50
ALT 4 ~ 43 U/L 32 69
ALP 36 ~ 104 U/L 79 58
Glucose 70 ~ 110 mg/dl 84 109
Total Cholesterol ~ 200 mg/dl 171 204
BUN 6.0 ~ 20.0 mg/dl 16 18.6
Creatinine 0.6 ~ 1.2 mg/dl 0.79 0.82
Direct Bilirubin ~ 0.3 mg/dl 0.19 0.24
LDH ~ 250 IU/L 269 424
CPK 50 ~ 200 U/L 182 317
Uric acid 3.0 ~ 5.5 mg/dl 3.5 3.4
CRP ~ 0.30 mg/dL 0.05 0.68
WBC white blood cell, RBC red blood cell, ESR erythrocyte sedimentation rate, AST aspartate aminotransferase, ALT alanine aminotransferase, ALP alkaline phosphatase, BUN blood urea nitrogen, LDH lactase dehydrogenase, CPK creatine phosphokinase, CRP C-reactive protein
On MRI, there was a diffuse edematous change in the bilateral masticator and extra-ocular muscles, accompanied by subcutaneous fat infiltration in the buccal and periorbital spaces. There was inhomogeneous enhancement of bilateral parotid glands. On PET-CT scan there was diffuse F-18-FDG uptake in the periorbital, frontalis, temporalis, and masseter muscles and the buccal and submandibular spaces without any increased uptake in the extremities or internal organs.
The Head and Neck Surgery and Radiology departments opined that a biopsy of the muscles would entail risk of complications such as bleeding and injury to the muscles. After a discussion with the patient regarding undergoing a muscle biopsy, a presumptive clinical diagnosis of an overlap syndrome of Sjogren’s syndrome with myositis was made and treatment with a medium-dose glucocorticoid (prednisolone 30 mg/day) begun; based on reports of orbital involvement, a good response to therapy, and benign prognosis in myositis associated with Sjogren’s syndrome[8–10]. On 16th day of treatment, the facial swelling was assessed as having completely resolved (Fig. 1b); however, the facial edema relapsed during subsequent days when glucocorticoid doses were lowered to less than 15 mg/day. Combination therapy with azathioprine, mycophenolate, or methotrexate for eight months was not effective in maintaining remission at acceptable doses of glucocorticoid, and the swelling aggravated considerably with the final relapse.
The patient finally agreed to further evaluation and was admitted to the hospital. On examination, there was aggravation of the facial edema (Fig. 1c). There was swelling of the right ankle, without tenderness. Neck flexion was preserved and motor power of extremities was assessed as five on a scale of zero to five. On laboratory evaluation, there was mild elevation of liver transaminases and CPK (Table 1). Serum aldolase was 7.9 U/L (reference < 7.6 U/L). On MRI of the head, there was aggravation of the inflammation (Fig. 1d). On ultrasonography of the right ankle, there was subcutaneous edema without evidence of synovitis. A series of evaluations to screen for malignancy including tumor makers (CA19-9, CEA, and CA125), esophagogastroduodenoscopy, colonoscopy, and mammography did not reveal abnormal findings.
A US-guided core-needle biopsy with an 18-gauge needle was performed in the right masseter muscle. Two pieces of tiny muscle tissue, measuring up to 0.5 × 0.1 cm, were obtained. On pathologic examination, there was moderate size variation of the myofibers, and endomysial and perimysial fibrosis. There was patchy CD4 + T cell-dominant lymphoplasmacytic infiltration in the stroma and atrophy of the myofibers, mainly at the periphery of the fascicles, being consistent with perifascicular atrophy. Necrosis of the myofibers was not prominent (Fig. 2). Based on these findings, a diagnosis of clinically amyopathic dermatomyositis was made.
Fig. 2 Biopsy specimens from the right masseter muscle. Hematoxylin and eosin staining shows moderate size variation of the myofibers and endomysial and perimysial fibrosis (white arrow). There is atrophy of the myofibers, mainly at the periphery of the fascicles (black arrow), which is consistent with perifascicular atrophy (a). Patchy lymphoplasmacytic infiltration (white arrow) is noted in the stroma (b), which consists of predominantly more CD4-positive cells (c) than CD8-positive cells (d) in immunohistochemical staining. All figures are at 200-fold magnification
Therapy with gamma-globulin (IVIG, 2.1 g/kg per month) in combination with prednisolone 30 mg/day was initiated, and after the first cycle the facial edema had resolved completely. However, when the dose of prednisolone was decreased to 15 mg/day, she made an earlier visit to the clinic with a relapse of the facial edema within six days. By the fourth cycle of IVIG, sustained remission could not be achieved. A course of rituximab (1.0 g twice, a week apart) in combination with methylprednisolone 40 mg/day was started. In the sixth week of rituximab therapy, when glucocorticoid dose was decreased to methylprednisolone 32 mg/day, she presented to the emergency room with altered mentality that began one day prior. On presentation, there was a fever of 38.7 °C, and the patient began mechanical ventilation immediately for hypoxemic respiratory failure. On chest X-ray, there was diffuse consolidation in both lung fields (Fig. 3b). On high-resolution CT, there was diffuse consolidation in the dependent portion of the lungs and diffuse ground glass opacity with relative sparing of the base of the lungs (Fig. 3c, d). The next day, the patient underwent bronchoscopy with bronchoalveolar lavage. The total cell count was 12 × 106 cells in 9 mL of fluid. Differential data of each cell type was as follows: macrophage 8 %, neutrophil 83 %, and lymphocyte 9 %. There was no bacteria isolated from the respiratory specimen, and a polymerase chain reaction (PCR) test for respiratory viruses including adenovirus, influenza virus, parainfluenza virus, and respiratory syncytial virus was negative. Pneumocystis jirovecii PCR and Gomori methenamine silver (GMS) staining were positive, and the patient began treatment with trimethoprim-sulfamethoxazole and glucocorticoids; but her hypoxemic respiratory failure progressed, and veno-venous extracorporeal (ECMO) membrane oxygenation was begun three days later. Given the lack of response to antibiotics therapy, glucocorticoid pulse and IV cyclosporine was started in consideration of rapidly progressive interstitial lung disease (RP-ILD). Over the next three weeks, despite the addition of polymyxin B-immobilized fiber column direct hemoperfusion (PMX-DHP)[11], there was no improvement in her hypoxemic respiratory failure, and according to the family’s will, the ECMO was weaned. On that day, she expired from respiratory failure.
Fig. 3 Chest radiographic images before and at the presentation of acute respiratory failure. Chest postero-anterior radiography taken about one month after initiating rituximab therapy shows no clear haziness or infiltration in both lung fields (a). At the presentation of acute respiratory failure with altered mentality (in the sixth week after starting rituximab) there was diffuse bilateral infiltration in both lung fields with relative sparing of both lower lung fields (b). Axial high-resolution computed tomography images show diffuse ground glass opacity in both upper lungs with consolidation in dependent areas (c); The lung base is relatively spared (d)
Discussion and Conclusions
This case, which posed significant diagnostic and therapeutic challenges, leaves important lessons for practice and research. First, isolated localized edema may be the initial manifestation of CADM. Such a case is considered very rare; we could find only one case reported in sufficient detail for us to verify the absence of muscle disease and other cutaneous manifestations, the prognosis of which was not known[12]. Second, although the patient presented initially with mild glucocorticoid-responsive facial edema, her course showed increasing extent of subcutaneous edema, decreasing response to immunomodulating therapy, and acute and severe involvement of the lungs leading to death. This suggests the prognosis cannot be predicted by the initially mild clinical manifestation alone.
Severe respiratory complications in idiopathic inflammatory myopathies such as DM pose considerable challenges to treatment, and the prognosis is poor[13, 14]. Differential diagnoses include cardiac complications, respiratory muscle weakness, drug hypersensitivity, RP-ILD, and severe and opportunistic infections[15, 16]. In many cases, it is difficult to arrive at a specific diagnosis, and there is a therapeutic dilemma of treating a severe autoimmune inflammation and a difficult-to-treat infection at the same time. Also in this case, there are a couple of explanations for the acute respiratory disease. First, the possibility of Pneumocystis pneumonia (PCP) should be considered. Prolonged glucocorticoid therapy is one of the risk factors for PCP in patients undergoing immunomodulating therapy for systemic autoimmune rheumatic diseases, and the patient was not receiving prophylaxis for it because of thrombocytopenia (< 50,000/mm3). Radiographic findings of acutely developed consolidation and ground glass opacity with relative sparing of the lung base is suggestive of PCP, and PCR and GMS staining were positive. In addition, even with appropriate treatment, mortality in fulminant PCP in non-HIV immunocompromised patients is high; in a recent study, the mortality rate in idiopathic inflammatory myopathy (including CADM) patients admitted to ICUs was 79.4 %, and PCP comprised approximately 20 % of the admissions[13]. Second, we believe the possibility of RP-ILD should be considered. From the early 2000s, associations between CADM and RP-ILD with poor prognosis were reported in Northeast Asia, including Korea, with mortality reaching approximately 50 %[17–19]. Later studies identified an association between anti-melanoma differentiation-associated protein 5 (MDA5) antibody and RP-ILD[20] [21], both of which are more common in CADM than in DM[22], and in Asians compared with Caucasians[21]. Recent studies report initial combination immunosuppressive therapies improved survival in RP-ILD in CADM[23], and that in the case of refractories a rescue therapy with tofacitinib may improve the outcome[24, 25]. Although we could not evaluate the presence of anti-MDA5 Ab in this case, which is a limitation of this study, rapidly progressive ILD was a possibility in the differential diagnosis of acute respiratory failure which did not respond to antibiotic therapy. Third, rituximab-induced lung disease could be considered. The patient developed acute respiratory symptoms five weeks and one day after the last rituximab infusion. This was in the period when late-onset respiratory illness may develop after rituximab infusion. However, late-onset rituximab-induced respiratory illness is less frequent than delayed-onset illness, shows a chronic course over weeks or months, and responds well to glucocorticoid therapy[26].
In conclusion, this case showed that CADM can initially manifest as a localized subcutaneous edema as the sole cutaneous manifestation but follow a progressive, refractory, and fatal course with major organ involvement, especially involving the lungs. A specific auto-antibody pattern may better predict the prognosis. Identification of the specific antibody profile and prompt initiation of therapy with proven efficacy may improve the outcome.
Authors’ contributions.
DHL analyzed clinical data and prepared the manuscript. YMK performed pathologic examination of the muscle biopsy samples and wrote the pathologic results. JHR performed the radiologic examination and muscle biopsy and contributed to writing. JHL, CSP, and SHK participated in critical care of the patient and contributed to writing. SL planned the study and performed analysis of data and literature. All authors read and approved the final manuscript.
Publisher’s Note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
Acknowledgements
Not applicable.
Authors' contributions
DHL analyzed clinical data and prepared the manuscript. YMK performed pathologic examination of the muscle biopsy samples and wrote the pathologic results. JHR performed the radiologic examination and muscle biopsy and contributed to writing. JHL, CSP, and SHK participated in critical care of the patient and contributed to writing. SL planned the study and performed analysis of data and literature. All authors read and approved the final manuscript.
Funding
Not applicable.
Availability of data and materials
Not applicable.
Ethics approval and consent to participate
This study was approved by the institutional review board of Haeundae Paik hospital (IRB file number: HPIRB 2019-08-016-001).
Consent for publication
Written informed consent was obtained from the patient, including the use of photographs of the face.
Competing interests
The authors declare that they have no competing interests. | Fatal | ReactionOutcome | CC BY | 33509162 | 18,862,926 | 2021-01-28 |
What was the outcome of reaction 'Respiratory failure'? | Clinically amyopathic dermatomyositis presenting with isolated facial edema complicated by acute respiratory failure: a case report.
BACKGROUND
In clinically amyopathic dermatomyositis, the hallmark cutaneous manifestations are the key to diagnosis. We report a case of clinically amyopathic dermatomyositis which presented with facial edema as the sole cutaneous manifestation and was later complicated by acute respiratory failure leading to death.
METHODS
A 58-year-old woman presented with edema of the face that had developed approximately one year ago. There was no weakness in the extremities, and the serum creatine kinase level was within normal range. On MRI, there was diffuse edematous change in the bilateral masticator and extra-ocular muscles, accompanied by subcutaneous fat infiltration in the face. A shared decision was made to defer muscle biopsy in the facial muscles. The facial swelling almost resolved with medium-dose glucocorticoid therapy but relapsed in days at glucocorticoid doses lower than 15 mg/day. Combination therapy with either azathioprine, mycophenolate, or methotrexate was not successful in maintaining clinical remission, and the swelling became more severe after relapses. A US-guided core-needle biopsy was subsequently performed in the right masseter muscle. On pathologic examination, there was a patchy CD4 + T cell-dominant lymphoplasmacytic infiltration in the stroma, necrosis of the myofibrils and prominent perifascicular atrophy. Based on those findings, a diagnosis of clinically amyopathic dermatomyositis was made. Therapy with gamma-globulin was not effective in maintaining remission. In the sixth week after starting rituximab, she presented to emergency room with altered mental state from acute respiratory failure. Despite treatment with antibiotics, glucocorticoid pulse, cyclosporin, and polymyxin B-immobilized fiber column direct hemoperfusion, she died three weeks later from persistent hypoxemic respiratory failure.
CONCLUSIONS
This case showed the full spectrum and severity of internal organ involvement of dermatomyositis, although the patient presented exclusively with subcutaneous edema limited to the head. The prognosis may be more closely associated with a specific auto-antibody profile than the benign-looking initial clinical manifestation. Close follow-up of lung involvement with prophylactic treatment for Pneumocystis pneumonia and prompt implementation of emerging therapeutic regimens may improve the outcome.
Background
Even before the classification of dermatomyositis (DM) was defined by Bohan and Peter in 1975, it was well known that there was a subgroup of patients who did not have muscle disease, regarded as amyopathic dermatomyositis (ADM)[1]. Studies have shown that there is evidence of subclinical muscle disease in MRI imaging and muscle biopsy in ADM leading to the concept of clinically amyopathic dermatomyositis (CADM), which is defined as absence of clinical muscle disease on physical examination and muscle enzyme analysis for at least six months[2]. In CADM, which represents about 11–20 % of dermatomyositis (DM)[3, 4], the hallmark cutaneous manifestations such as Heliotrope rash, Gottron’s papules, and Gottron’s sign are the key to diagnosis.
There has been a report that suggested that subcutaneous edema is a cutaneous manifestation of DM because it can be the only skin lesion at presentation[5]. In the case series, edematous DM comprised 6 % (5/86) of a DM cohort. In the muscle biopsies of the five cases of edematous DM, there were frequent microinfarctions, which were considered to be induced by vasculitis producing micro-ischemia. In the reported five cases and review of 19 reported cases, there were six cases (3/5 and 3/19, respectively) in which subcutaneous edema was the sole cutaneous manifestation, but all had clinical muscle disease, suggesting that CADM presenting exclusively with subcutaneous edema is very rare. In this study, we report a case of CADM which presented with facial edema as the sole cutaneous manifestation and was later complicated by acute respiratory failure leading to mortality.
Case presentation
A 58-year-old woman presented with edema of the face that had developed approximately one year prior. It was not painful nor pruritic, but she felt it was more prominent on the left side. Courses of antibiotic therapy for a presumed diagnosis of cellulitis had not been effective, but glucocorticoids greatly improved the swelling, which relapsed rapidly with tapering. One week prior, as another course of glucocorticoids prescribed for a diagnosis of angioedema was tapered out, her facial edema relapsed, accompanied by tiny, pruritic vesicular lesions on the chin. Although she was evaluated in neurology and dental clinics, no specific diagnosis was made. She reported ‘dryness’ and ‘itchiness’ of the eyes, but not in the oral cavity.
On evaluation, there was bilateral swelling of the malar and temporal area of the face, involving the periorbital area and eyelid in the left side. On the chin, there was eczematoid vesicular eruption (Fig. 1a). There was no abnormal finding on the examination of the chest and abdomen. There was no edema or rash in the trunk or extremities. Neck flexion was preserved, and the power of the extremities’ motor function was evaluated as five on a scale of zero to five. On ophthalmologic examination, there was swelling of the left upper eyelid, and the anterior chamber was clear and deep in both eyes. Five-minute Schirmer test result was 6 mm in the right eye and 8 mm in the left eye (reference value < 5 mm for dry eye disease, but known to have low sensitivity in mild or moderate cases)[6]. Ocular staining score was 1 and 2 in the right and left eye, respectively (reference value ≥ 5 for classification of primary Sjögren’s syndrome)[7].
Fig. 1 Isolated facial edema and subclinical facial muscle involvement. At initial presentation there was bilateral swelling of the face and of the left eyelid, accompanied by eczematoid eruption on the chin (a). After approximately two weeks of medium-dose glucocorticoid therapy the edema and the lesions were completely resolved (b). However, combination therapy with either azathioprine, mycophenolate, or methotrexate was not successful in maintaining remission at a prednisolone dose lower than 15 mg per day. At the last relapse, there was marked aggravation of facial and eyelid edema (c). Gadolinium-enhanced MRI scan of the head shows diffuse edematous change with enhancement of bilateral masticator muscles (d, masseter muscle [yellow arrow] and lateral pterygoid muscle [black arrow]). There was also swelling of bilateral extra-ocular muscles and edematous change with fat infiltration in the subcutaneous tissues of the anterior scalp, periorbital area, buccal space, and anterior cervical fascia (not shown)
On the initial laboratory evaluation, there were no abnormalities, and the serum creatine phosphokinase (CPK) level was within normal range (Table 1). On serologic evaluation, antinuclear antibody was positive up to 1:160 in titer in homogeneous pattern, but anti-dsDNA Ab and anti-histone Ab was negative. Anti-SSA (> 240 U/mL) and anti-SSB (18 U/mL) antibodies were positive (fluorescent enzyme immunoassay, reference value < 7 U/mL for both); anti-RNP and anti-Smith Ab, negative. Anti-Jo1 antibody and anti-SRP antibody were negative. Anti-neutrophil cytoplasmic antibody was negative and IgG4 level was within normal range: 102 mg/dL (reference 30 ~ 201 mg/dL).
Table 1 Laboratory data
Variable Reference range At initial presentation At the second admission
WBC 4.0 ~ 10.0 × 109/L 5.2 2.84
RBC 4.2 ~ 5.4 × 1012/L 4.23 4.38
Hgb 12.0 ~ 16.0 g/dL 12.4 13.7
Platelet 140 ~ 440 × 109/L 230 166
Differential Count
Neutrophil 40 ~ 80 % 57.8 66.8
Lymphocyte 15 ~ 50 % 30.2 20.8
Monocyte 2 ~ 11 % 7.9 9.2
Eosinophil 0 ~ 7 % 3.5 2.8
Basophil 0 ~ 1 % 0.6 0.4
ESR ~ 120 mm 14 21
Total Protein 6.0 ~ 8.0 g/dl 7.4 7.1
Albumin 3.5 ~ 5.2 g/dl 4.3 4.1
Total Bilirubin ~ 1.2 mg/dl 0.64 1.01
AST 7 ~ 38 U/L 36 50
ALT 4 ~ 43 U/L 32 69
ALP 36 ~ 104 U/L 79 58
Glucose 70 ~ 110 mg/dl 84 109
Total Cholesterol ~ 200 mg/dl 171 204
BUN 6.0 ~ 20.0 mg/dl 16 18.6
Creatinine 0.6 ~ 1.2 mg/dl 0.79 0.82
Direct Bilirubin ~ 0.3 mg/dl 0.19 0.24
LDH ~ 250 IU/L 269 424
CPK 50 ~ 200 U/L 182 317
Uric acid 3.0 ~ 5.5 mg/dl 3.5 3.4
CRP ~ 0.30 mg/dL 0.05 0.68
WBC white blood cell, RBC red blood cell, ESR erythrocyte sedimentation rate, AST aspartate aminotransferase, ALT alanine aminotransferase, ALP alkaline phosphatase, BUN blood urea nitrogen, LDH lactase dehydrogenase, CPK creatine phosphokinase, CRP C-reactive protein
On MRI, there was a diffuse edematous change in the bilateral masticator and extra-ocular muscles, accompanied by subcutaneous fat infiltration in the buccal and periorbital spaces. There was inhomogeneous enhancement of bilateral parotid glands. On PET-CT scan there was diffuse F-18-FDG uptake in the periorbital, frontalis, temporalis, and masseter muscles and the buccal and submandibular spaces without any increased uptake in the extremities or internal organs.
The Head and Neck Surgery and Radiology departments opined that a biopsy of the muscles would entail risk of complications such as bleeding and injury to the muscles. After a discussion with the patient regarding undergoing a muscle biopsy, a presumptive clinical diagnosis of an overlap syndrome of Sjogren’s syndrome with myositis was made and treatment with a medium-dose glucocorticoid (prednisolone 30 mg/day) begun; based on reports of orbital involvement, a good response to therapy, and benign prognosis in myositis associated with Sjogren’s syndrome[8–10]. On 16th day of treatment, the facial swelling was assessed as having completely resolved (Fig. 1b); however, the facial edema relapsed during subsequent days when glucocorticoid doses were lowered to less than 15 mg/day. Combination therapy with azathioprine, mycophenolate, or methotrexate for eight months was not effective in maintaining remission at acceptable doses of glucocorticoid, and the swelling aggravated considerably with the final relapse.
The patient finally agreed to further evaluation and was admitted to the hospital. On examination, there was aggravation of the facial edema (Fig. 1c). There was swelling of the right ankle, without tenderness. Neck flexion was preserved and motor power of extremities was assessed as five on a scale of zero to five. On laboratory evaluation, there was mild elevation of liver transaminases and CPK (Table 1). Serum aldolase was 7.9 U/L (reference < 7.6 U/L). On MRI of the head, there was aggravation of the inflammation (Fig. 1d). On ultrasonography of the right ankle, there was subcutaneous edema without evidence of synovitis. A series of evaluations to screen for malignancy including tumor makers (CA19-9, CEA, and CA125), esophagogastroduodenoscopy, colonoscopy, and mammography did not reveal abnormal findings.
A US-guided core-needle biopsy with an 18-gauge needle was performed in the right masseter muscle. Two pieces of tiny muscle tissue, measuring up to 0.5 × 0.1 cm, were obtained. On pathologic examination, there was moderate size variation of the myofibers, and endomysial and perimysial fibrosis. There was patchy CD4 + T cell-dominant lymphoplasmacytic infiltration in the stroma and atrophy of the myofibers, mainly at the periphery of the fascicles, being consistent with perifascicular atrophy. Necrosis of the myofibers was not prominent (Fig. 2). Based on these findings, a diagnosis of clinically amyopathic dermatomyositis was made.
Fig. 2 Biopsy specimens from the right masseter muscle. Hematoxylin and eosin staining shows moderate size variation of the myofibers and endomysial and perimysial fibrosis (white arrow). There is atrophy of the myofibers, mainly at the periphery of the fascicles (black arrow), which is consistent with perifascicular atrophy (a). Patchy lymphoplasmacytic infiltration (white arrow) is noted in the stroma (b), which consists of predominantly more CD4-positive cells (c) than CD8-positive cells (d) in immunohistochemical staining. All figures are at 200-fold magnification
Therapy with gamma-globulin (IVIG, 2.1 g/kg per month) in combination with prednisolone 30 mg/day was initiated, and after the first cycle the facial edema had resolved completely. However, when the dose of prednisolone was decreased to 15 mg/day, she made an earlier visit to the clinic with a relapse of the facial edema within six days. By the fourth cycle of IVIG, sustained remission could not be achieved. A course of rituximab (1.0 g twice, a week apart) in combination with methylprednisolone 40 mg/day was started. In the sixth week of rituximab therapy, when glucocorticoid dose was decreased to methylprednisolone 32 mg/day, she presented to the emergency room with altered mentality that began one day prior. On presentation, there was a fever of 38.7 °C, and the patient began mechanical ventilation immediately for hypoxemic respiratory failure. On chest X-ray, there was diffuse consolidation in both lung fields (Fig. 3b). On high-resolution CT, there was diffuse consolidation in the dependent portion of the lungs and diffuse ground glass opacity with relative sparing of the base of the lungs (Fig. 3c, d). The next day, the patient underwent bronchoscopy with bronchoalveolar lavage. The total cell count was 12 × 106 cells in 9 mL of fluid. Differential data of each cell type was as follows: macrophage 8 %, neutrophil 83 %, and lymphocyte 9 %. There was no bacteria isolated from the respiratory specimen, and a polymerase chain reaction (PCR) test for respiratory viruses including adenovirus, influenza virus, parainfluenza virus, and respiratory syncytial virus was negative. Pneumocystis jirovecii PCR and Gomori methenamine silver (GMS) staining were positive, and the patient began treatment with trimethoprim-sulfamethoxazole and glucocorticoids; but her hypoxemic respiratory failure progressed, and veno-venous extracorporeal (ECMO) membrane oxygenation was begun three days later. Given the lack of response to antibiotics therapy, glucocorticoid pulse and IV cyclosporine was started in consideration of rapidly progressive interstitial lung disease (RP-ILD). Over the next three weeks, despite the addition of polymyxin B-immobilized fiber column direct hemoperfusion (PMX-DHP)[11], there was no improvement in her hypoxemic respiratory failure, and according to the family’s will, the ECMO was weaned. On that day, she expired from respiratory failure.
Fig. 3 Chest radiographic images before and at the presentation of acute respiratory failure. Chest postero-anterior radiography taken about one month after initiating rituximab therapy shows no clear haziness or infiltration in both lung fields (a). At the presentation of acute respiratory failure with altered mentality (in the sixth week after starting rituximab) there was diffuse bilateral infiltration in both lung fields with relative sparing of both lower lung fields (b). Axial high-resolution computed tomography images show diffuse ground glass opacity in both upper lungs with consolidation in dependent areas (c); The lung base is relatively spared (d)
Discussion and Conclusions
This case, which posed significant diagnostic and therapeutic challenges, leaves important lessons for practice and research. First, isolated localized edema may be the initial manifestation of CADM. Such a case is considered very rare; we could find only one case reported in sufficient detail for us to verify the absence of muscle disease and other cutaneous manifestations, the prognosis of which was not known[12]. Second, although the patient presented initially with mild glucocorticoid-responsive facial edema, her course showed increasing extent of subcutaneous edema, decreasing response to immunomodulating therapy, and acute and severe involvement of the lungs leading to death. This suggests the prognosis cannot be predicted by the initially mild clinical manifestation alone.
Severe respiratory complications in idiopathic inflammatory myopathies such as DM pose considerable challenges to treatment, and the prognosis is poor[13, 14]. Differential diagnoses include cardiac complications, respiratory muscle weakness, drug hypersensitivity, RP-ILD, and severe and opportunistic infections[15, 16]. In many cases, it is difficult to arrive at a specific diagnosis, and there is a therapeutic dilemma of treating a severe autoimmune inflammation and a difficult-to-treat infection at the same time. Also in this case, there are a couple of explanations for the acute respiratory disease. First, the possibility of Pneumocystis pneumonia (PCP) should be considered. Prolonged glucocorticoid therapy is one of the risk factors for PCP in patients undergoing immunomodulating therapy for systemic autoimmune rheumatic diseases, and the patient was not receiving prophylaxis for it because of thrombocytopenia (< 50,000/mm3). Radiographic findings of acutely developed consolidation and ground glass opacity with relative sparing of the lung base is suggestive of PCP, and PCR and GMS staining were positive. In addition, even with appropriate treatment, mortality in fulminant PCP in non-HIV immunocompromised patients is high; in a recent study, the mortality rate in idiopathic inflammatory myopathy (including CADM) patients admitted to ICUs was 79.4 %, and PCP comprised approximately 20 % of the admissions[13]. Second, we believe the possibility of RP-ILD should be considered. From the early 2000s, associations between CADM and RP-ILD with poor prognosis were reported in Northeast Asia, including Korea, with mortality reaching approximately 50 %[17–19]. Later studies identified an association between anti-melanoma differentiation-associated protein 5 (MDA5) antibody and RP-ILD[20] [21], both of which are more common in CADM than in DM[22], and in Asians compared with Caucasians[21]. Recent studies report initial combination immunosuppressive therapies improved survival in RP-ILD in CADM[23], and that in the case of refractories a rescue therapy with tofacitinib may improve the outcome[24, 25]. Although we could not evaluate the presence of anti-MDA5 Ab in this case, which is a limitation of this study, rapidly progressive ILD was a possibility in the differential diagnosis of acute respiratory failure which did not respond to antibiotic therapy. Third, rituximab-induced lung disease could be considered. The patient developed acute respiratory symptoms five weeks and one day after the last rituximab infusion. This was in the period when late-onset respiratory illness may develop after rituximab infusion. However, late-onset rituximab-induced respiratory illness is less frequent than delayed-onset illness, shows a chronic course over weeks or months, and responds well to glucocorticoid therapy[26].
In conclusion, this case showed that CADM can initially manifest as a localized subcutaneous edema as the sole cutaneous manifestation but follow a progressive, refractory, and fatal course with major organ involvement, especially involving the lungs. A specific auto-antibody pattern may better predict the prognosis. Identification of the specific antibody profile and prompt initiation of therapy with proven efficacy may improve the outcome.
Authors’ contributions.
DHL analyzed clinical data and prepared the manuscript. YMK performed pathologic examination of the muscle biopsy samples and wrote the pathologic results. JHR performed the radiologic examination and muscle biopsy and contributed to writing. JHL, CSP, and SHK participated in critical care of the patient and contributed to writing. SL planned the study and performed analysis of data and literature. All authors read and approved the final manuscript.
Publisher’s Note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
Acknowledgements
Not applicable.
Authors' contributions
DHL analyzed clinical data and prepared the manuscript. YMK performed pathologic examination of the muscle biopsy samples and wrote the pathologic results. JHR performed the radiologic examination and muscle biopsy and contributed to writing. JHL, CSP, and SHK participated in critical care of the patient and contributed to writing. SL planned the study and performed analysis of data and literature. All authors read and approved the final manuscript.
Funding
Not applicable.
Availability of data and materials
Not applicable.
Ethics approval and consent to participate
This study was approved by the institutional review board of Haeundae Paik hospital (IRB file number: HPIRB 2019-08-016-001).
Consent for publication
Written informed consent was obtained from the patient, including the use of photographs of the face.
Competing interests
The authors declare that they have no competing interests. | Fatal | ReactionOutcome | CC BY | 33509162 | 19,217,583 | 2021-01-28 |
Give an alphabetized list of all active substances of drugs taken by the patient who experienced 'Anaemia neonatal'. | Meropenem-induced pancytopenia in a preterm neonate: a case report.
BACKGROUND
A post-marketing surveillance study has reported an association between meropenem use and the incidence of hematologic abnormalities, including leukopenia, thrombocytopenia, hemolysis, and neutropenia, but the precise incidence in neonates is unknown. Here, we report meropenem-induced pancytopenia in a preterm neonate.
METHODS
A preterm newborn Pakistani received intravenous meropenem 40 mg/kg every 8 hours to treat Klebsiella pneumoniae in blood cultures and suspected meningitis. The baby developed severe thrombocytopenia, with a platelet count of 22 × 103 cells/mm3, low hemoglobin level of 9.7 g/dl, and low absolute neutrophil count (ANC) of 816 cells/mm3 on days 3, 14, and 17 of meropenem therapy, respectively. Based on the blood culture and institutional guidelines, meropenem treatment was continued with monitoring and supportive care for a total of 19 days. After discontinuation of meropenem, the baby was monitored continuously for hematological changes, and low counts persisted for 3 days. ANC improved to > 1500 cells/mm3 on the fourth day, and the platelet count reached > 150 × 103 cells/mm3 for the first time on the seventh day of meropenem discontinuation. All subsequent complete blood count (CBC) reports showed improving trends. The baby was discharged on the 48th day of life (DOL), with follow-up monitoring of CBC. The baby was kept on iron supplements, and hemoglobin level of 11.2 g/dl was observed on the 59th DOL.
CONCLUSIONS
Neonatal pancytopenia may lead to serious health complications; therefore, clinicians and pharmacists need to vigilantly monitor CBC in this vulnerable population, even when administering meropenem in septic doses for the recommended duration.
Background
Pancytopenia is defined as reduced white blood cell (WBC) count, hemoglobin, and platelet count. Pancytopenia occurs when hemoglobin is < 13 g/dl in males and < 12 g/dl in females, absolute neutrophil count (ANC) is < 1500 cells/mm3, and platelet count is < 150 × 103 cells/mm3 [1]. Pancytopenia is considered severe if a patient experiences two or more of the following: hemoglobin < 7 g/dl, ANC < 500 cells/mm3, and platelet count < 50 × 103 cells/mm3. The mechanism underlying pancytopenia mainly involves bone marrow infiltration, bone marrow aplasia, and blood cell destruction that results in peripheral blood leakage [1]. Suppression of bone marrow varies widely in the pediatric population but may occur due to toxins, infection, or malignant cell infiltrates that can lead to hypocellular bone marrow function. Drug-induced pancytopenia is also a rare but secondary cause of bone marrow suppression due to direct bone marrow toxicity, immune-mediated (complement or antibody-mediated) cell destruction, and hapten formation, and directly affects myeloid precursors [2, 3]. An in vitro study of several beta-lactam antibiotics established the presence of well-differentiated myeloid cells and copious granulocyte precursors along with dose-dependent suppression of granulopoiesis [4]. Antibody-mediated hemolytic anemia and thrombocytopenia have also been established in meropenem-treated patients [5, 6]. Several medications can cause pancytopenia including chemotherapeutics, antiepileptics, antidepressants, and antibiotics [3, 5, 7]. A case–control epidemiological surveillance study was conducted over a follow-up period of 78.7 million person-years to assess the incidence of drug-induced agranulocytosis. Around 396 confirmed cases of acute neutropenia were observed, with an overall incidence of 3.5:1 million per year [8]. It was found that agranulocytosis clearly increased the risk of mortality, with a fatality rate of 9.1%. The most common drugs causing agranulocytosis were dipyrone (16%), beta-lactam antibiotics (12.0 %), ticlopidine (11.1%), antithyroid drugs (7.2%), and sulfonamide antibiotics (5.4%) [8].
Meropenem is one of the beta-lactam antibiotics that can cause serious and life-threatening neutropenia. It is a bactericidal broad-spectrum antibiotic with gram-positive, gram-negative, and anaerobic coverage, and is mainly used in the treatment of severe gram-negative infections in neonates including severe sepsis, meningitis, and complicated intra-abdominal infections such as necrotizing enterocolitis (NEC), one of the most common gastrointestinal emergencies and a major cause of morbidity and mortality in preterm neonates. For improved clinical outcomes, early recognition and aggressive management with broad-spectrum or combination antimicrobial agents is most often undertaken to treat NEC [9]. Because of its broad-spectrum activity, meropenem is an agent of great utility [10]. Based on the increasing trends of morbidity and mortality due to multidrug-resistant gram-negative bacterial infections in our neonatal intensive care unit (NICU), and following institutional guidelines, other antibiotics such as vancomycin and colistin are also used [11–13] after infectious disease (ID) consultation. The most common adverse effects of meropenem are constipation or diarrhea, nausea, vomiting, rashes, and diaper-area moniliasis in pediatric patients [14]. Some cases of meropenem-induced neutropenia have been reported [15]. However, no known case of meropenem-induced pancytopenia in neonates has yet been published. Here we report an event of meropenem-induced pancytopenia in a neonate admitted to the NICU of a tertiary-care hospital.
Case presentation
A newborn Pakistani baby was transferred to the intensive care unit due to prematurity, low birth weight, and intrauterine growth retardation. Her birth weight was 0.71 kg and APGAR scores were 3 at 1 minute and 4 at 5 minutes. Delivered by emergency C-section at 29 weeks due to raised blood pressure and fetal distress, she was initially kept on continuous positive airway pressure (CPAP) and given nothing through the mouth, and total parenteral nutrition (TPN) was started. Caffeine was loaded at 20 mg/kg and continued as the standard of care for apnea of prematurity. A prophylactic dose of 1 mg of vitamin K was given. During the first 24 hours, complete blood count (CBC) results were WBC of 18.3 × 103 cells/mm3, ANC of 1244 cells/mm3, platelet count of 166 × 103 cells/mm3, and hemoglobin of 17.8 g/dl. On the second day of life (DOL), ampicillin and gentamicin were started as empirical therapy, and the CBC report showed WBC 4 × 103 cells/mm3, ANC of 760 cells/mm3, platelet count of 152 × 103 cells/mm3, and hemoglobin of 15.9 g/dl. In addition, fluconazole was started as antifungal prophylaxis. The patient was given phototherapy. Chest X-ray and ultrasound of the head were performed, with normal findings. CPAP was tapered to high flow on merit, and blood culture was sent.
On the fourth DOL, the baby developed issues of severe respiratory distress and abdominal distension along with metabolic acidosis. She was intubated and kept on synchronized intermittent mandatory ventilation (SIMV) mode. The CBC results showed ANC of 912 cells/mm3, platelet count of 99 × 103 cells/mm3, and hemoglobin of 12.7 g/dl. Inotropic support was started, and antibiotics were escalated to meropenem 20 mg/kg every 12 hours, vancomycin 10 mg/kg once daily, and colistin at a loading dose of 5 mg/kg with a maintenance dose of 1.5 mg/kg every 12 hours. Blood culture showed no growth. After ID consult, vancomycin was discontinued on the third day and a decision was made to continue meropenem and colistin [11–13] to manage NEC and sepsis.
On the fifth DOL, echocardiogram was performed and showed patent ductus arteriosus (PDA) of 3 mm with severe persistent pulmonary hypertension of the newborn (PPHN). Acetaminophen was started for the next 5 days. On the sixth day of meropenem therapy, the platelet count dropped to 42 × 103 cells/mm3, treated in line with sepsis-associated thrombocytopenia [16], and managed by transfusion of 10 ml/kg platelet units [17]. Meropenem and colistin were discontinued on the eighth day of therapy, and trophic feeding was started. An echocardiogram was repeated on day 11, which showed a closed PDA and moderate PPHN. On the 18th DOL, the child was successfully extubated and kept on high-flow oxygen. There was slow progress in feeding.
On the 22nd DOL, the baby had tachycardia and an episode of 99.7 °F fever. Thus, septic workup was done and showed WBC count of 17.4 × 103 cells/mm3, ANC of 12,632.4 cells/mm3, and platelets of 203 × 103 cells/mm3. C-reactive protein (CRP) was 77 mg/l and renal function was normal (blood urea nitrogen [BUN] of 11 mg/dl and creatinine of 0.2 mg/dl). Meropenem was started in meningitic doses of 40 mg/kg every 8 hours [10] along with vancomycin 15 mg/kg every 12 hours.
In the microbiological investigation, urine and cerebrospinal fluid (CSF) cultures were found to be negative, but the blood culture was positive for Staphylococcus species (not aureus). Blood culture repeated after 48 hours was positive for carbapenem-sensitive Klebsiella pneumoniae. The baby was moved to the isolation room. On the 24th DOL, the baby developed severe thrombocytopenia, with a platelet count of 22 × 103 cells/mm3, managed with the transfusion of 10 ml/kg platelet units [17].
On the 25th DOL, an episode of generalized tonic-clonic fit occurred for which single-dose diazepam and a loading dose of phenobarbitone were given initially and then continued with maintenance doses of phenobarbitone. Due to significant metabolic acidosis and desaturation, the baby was re-intubated. After ID consult, meropenem was continued in meningitic doses and vancomycin was discontinued. SIMV and a central line were placed. TPN was started with nothing per oral status.
Blood gases were monitored, and the baby was extubated after 4 days and switched to CPAP. Phenobarbitone was discontinued after 6 days of therapy, and the baby was seizure-free through the remainder of the hospital stay. All repeat blood cultures were negative for any growth including CSF culture. The ID team was on board and decided to continue meropenem for a total of 14 days post-negative culture in septic doses of 20 mg/kg, and vancomycin was discontinued after 6 days. All repeated blood cultures obtained on the 27th and 30th DOL confirmed no pathogenic growth.
On the 33rd DOL, the CBC report showed WBC of 8.7 × 103 cells/mm3, ANC of 4576 cells/mm3, platelets of 78 × 103 cells/mm3, and hemoglobin of 10.8 g/dl. On the 36th DOL, the CBC report showed WBC of 5.1 × 103 cells/mm3, ANC of 2917 cells/mm3, platelets of 29 × 103 cells/mm3, and hemoglobin of 9.2 g/dl. The baby was managed for thrombocytopenia with platelet transfusion.
On the 37th DOL, hemoglobin dropped to 8.3 g/dl in the evening, and platelet count improved to 63 × 103 cells/mm3, WBC was 4.8 × 103 cells/mm3, and ANC was 1285 cells/mm3. On the 39th DOL, a marked reduction was observed in ANC to 816 cells/mm3, platelets of 38 × 103 cells/mm3, and hemoglobin of 8.3 g/dl, and the baby received blood transfusion to manage it. For constant issues, a hematological consult was taken and a decision was made to manage the baby symptomatically with 10 ml/kg platelet units at a platelet count < 50 [17] and 15 ml/kg packed cell transfusion at hemoglobin < 10 g/dl [18].
On the 40th DOL, meropenem was discontinued 14 days after negative culture (total of 19 days of meropenem therapy). On the same day the platelet count was 34 × 103 cells/mm3, ANC was 818 cells/mm3, and hemoglobin was 10.2 g/dl, and the baby was transfused to manage these issues. After discontinuation of meropenem, the baby was continuously monitored for hematological changes, and low counts persisted for 3 days. Improved ANC of > 1500 cells/mm3 was reported on the fourth day, and platelet count of > 150 × 103 cells/mm3 was reported for the first time on the sixth day of meropenem discontinuation, but hemoglobin was still low (Fig 1). CPAP was tapered gradually to nasal prongs. The peripherally inserted central catheter was removed, and orogastric (OG) tube feeding was commenced. The baby was discharged on the 48th DOL on iron supplements with follow-up monitoring of CBC. Hemoglobin level of 11.2 g/dl was found on the 59th DOL.Fig. 1. Hematological changes and timing of medication during hospitalization
Discussion
Drug-induced pancytopenia is a rare hematological problem in neonatal clinical practices, evaluated based on a complete underlying pathological history, physical examination, and vigilant interpretation of biochemical, radiological, histopathological, and hematological findings [19]. Concerns have been raised about hematological adverse effects of several beta-lactamase inhibitors [8]. This neonatal case documents meropenem-induced pancytopenia and emphasizes cautious laboratory monitoring for patients receiving meropenem therapy.
Sepsis is another known etiology of pancytopenia. Although the neonate in the present case had a blood culture positive for K. pneumoniae, the results of all repeated blood cultures were negative, showing the resolution of sepsis. Van Tuyl et al. [20] also reported a case of a neonate receiving meropenem in meningitic doses of 40 mg/kg/day to treat meropenem-susceptible Enterobacter cloacae in blood culture. The baby developed meropenem-induced neutropenia on the 13th day of therapy, with ANC of 288 cells/mm3. The decision was made to discontinue meropenem on the 19th day of therapy instead of the initially planned 21 days. In the present case, the baby continued to receive meropenem treatment and was managed for hematological problems based on institutional guidelines and culture sensitivity. Initially, hematological changes were not considered as directly meropenem-induced.
Recently published reports also support the notion of carbapenem-induced hematological disorders. A case report by Estella and colleagues [21] described meropenem-induced pancytopenia in a 3-year-old patient at 100 mg/kg given every 8 hours to manage the regrowth of meropenem-sensitive Morganella morganii in CSF cultures. Huang et al. [6] reported a case of meropenem-induced immune thrombocytopenia in a 59-year-old patient, by detecting meropenem-dependent platelet antibodies and platelet count recovery after discontinuation of meropenem. Oka et al. [5] reported the development of severe anemia with clinical signs in a 76-year-old female patient, who received 2 g meropenem per day. On further investigation, they found that a direct antiglobulin test (DAT) was positive for immunoglobulin G (IgG) and C3d, and reported the presence of meropenem-dependent antibodies in the patient’s serum [5].
The absence of drug-dependent antibody testing and bone marrow aspiration prevent us from drawing a firm conclusion regarding the mechanism of meropenem-induced pancytopenia in the present case. However, the hematological findings with the progressive development of thrombocytopenia, anemia, and then neutropenia suggest a possible mechanism of suppression of granulopoiesis or antibody-mediated destruction, as reported in recent studies [5, 6].
During hospitalization, the neonate received other medications, which have been reported to exert hematological effects. The baby initially received ampicillin, gentamicin, and fluconazole, and then received meropenem, colistin, vancomycin, and phenobarbital. However, severe thrombocytopenia developed on the sixth day of the first course of meropenem therapy, when the baby was also on colistin and fluconazole. This issue was resolved when meropenem was discontinued. During the second course of meropenem therapy, the baby again developed severe thrombocytopenia on the third day, while also receiving vancomycin, fluconazole, and phenobarbital. Phenobarbital-induced hematological abnormalities are reported in animal and adult studies [22, 23], and therefore it was discontinued on the sixth day. No seizures were observed but counts did not improve. However, the baby developed severe anemia and neutropenia while receiving fluconazole and meropenem only. After meropenem discontinuation, severe anemia and neutropenia showed a resolving trend for 3 days. Severe neutropenia resolved on the fourth day, and hemoglobin was reported at > 10 g/dl without transfusion on the seventh day of meropenem discontinuation, while fluconazole therapy was continued from the beginning until the 56th DOL, which further confirms the association of meropenem-induced hematological changes in this baby. It was also confirmed that the baby did not experience any additional infection even though she was not discharged on any antibiotic, which correlates with the fast recovery of blood counts after meropenem discontinuation.
Conclusions
In the present neonatal case, the gradual onset of hematological irregularities correlates with the commencement of meropenem therapy, and our observations are also verified by previously published evidence. The follow-up CBC count further established the resolution of pancytopenia after discontinuation of meropenem. Neonatal pancytopenia may lead to serious health complications; therefore, clinicians and pharmacists need to vigilantly monitor CBC counts in this vulnerable population, even when administering meropenem in septic doses for the recommended duration.
Patient perspective
From the perspective of the patient’s father, it was a rare case to have such kind of adverse events in a neonate with the normal treatment regimen. He was shared about all the events and he admired the team for the timely and effectively managing the issues and finally 100% recovery on the follow-ups.
Abbreviations
ANCAbsolute neutrophil count
CBCComplete blood count
DOLDay of life
CPAPContinuous positive airway pressure
TPNTotal parenteral nutrition
SIMVSynchronized intermittent mandatory ventilation
NECNecrotizing enterocolitis
PDAPatent ductus arteriosus
PPHNPersistent pulmonary hypertension of the newborn
CRPC-reactive protein
IDInfectious disease
Publisher's Note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
Acknowledgements
We acknowledge the kind support of Abdul Moiz Hussain for providing technical support in the process of final submission and language review. This study was conducted in the neonatal intensive care unit of Aga Khan University Hospital, Karachi, Pakistan.
Authors’ contributions
GA: Substantial contributions to the conception or design of the work. Performed the study, analysis, or interpretation of patient information. Major contributor in writing the manuscript. KH: Supervised the study and analyzed and interpreted the patient data regarding the hematological changes with therapy. Revised the work critically for important intellectual content. SS: Supervised the study and analyzed and interpreted the patient data regarding the hematological changes with therapy. Final approval of the version published. NM: Wrote the initial draft of the case report. AM: Co-wrote the initial draft. SI: data collection and interpretation. JI: data collection and interpretation. All authors read and approved the final manuscript.
Funding
No source of funding in the research.
Availability of data and materials
All data generated or analyzed during this study are included in the published article. The data sets used and/or analyzed during the current study are available from the corresponding author on reasonable request. Please contact the author for data requests.
Ethics approval and consent to participate
This case report was exempted from formal approval by the Ethical Review Committee, Aga Khan University Karachi, Pakistan.
Consent for publication
Written informed consent was obtained from the patient’s legal guardian(s) for publication of this case report and any accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.
Competing interests
The authors declare that they have no competing interests. | ACETAMINOPHEN, AMPICILLIN, CAFFEINE, COLISTIN, DIAZEPAM, FLUCONAZOLE, MEROPENEM, PHENOBARBITAL, VANCOMYCIN | DrugsGivenReaction | CC BY | 33509295 | 18,915,789 | 2021-01-29 |
Give an alphabetized list of all active substances of drugs taken by the patient who experienced 'Neutropenia neonatal'. | Meropenem-induced pancytopenia in a preterm neonate: a case report.
BACKGROUND
A post-marketing surveillance study has reported an association between meropenem use and the incidence of hematologic abnormalities, including leukopenia, thrombocytopenia, hemolysis, and neutropenia, but the precise incidence in neonates is unknown. Here, we report meropenem-induced pancytopenia in a preterm neonate.
METHODS
A preterm newborn Pakistani received intravenous meropenem 40 mg/kg every 8 hours to treat Klebsiella pneumoniae in blood cultures and suspected meningitis. The baby developed severe thrombocytopenia, with a platelet count of 22 × 103 cells/mm3, low hemoglobin level of 9.7 g/dl, and low absolute neutrophil count (ANC) of 816 cells/mm3 on days 3, 14, and 17 of meropenem therapy, respectively. Based on the blood culture and institutional guidelines, meropenem treatment was continued with monitoring and supportive care for a total of 19 days. After discontinuation of meropenem, the baby was monitored continuously for hematological changes, and low counts persisted for 3 days. ANC improved to > 1500 cells/mm3 on the fourth day, and the platelet count reached > 150 × 103 cells/mm3 for the first time on the seventh day of meropenem discontinuation. All subsequent complete blood count (CBC) reports showed improving trends. The baby was discharged on the 48th day of life (DOL), with follow-up monitoring of CBC. The baby was kept on iron supplements, and hemoglobin level of 11.2 g/dl was observed on the 59th DOL.
CONCLUSIONS
Neonatal pancytopenia may lead to serious health complications; therefore, clinicians and pharmacists need to vigilantly monitor CBC in this vulnerable population, even when administering meropenem in septic doses for the recommended duration.
Background
Pancytopenia is defined as reduced white blood cell (WBC) count, hemoglobin, and platelet count. Pancytopenia occurs when hemoglobin is < 13 g/dl in males and < 12 g/dl in females, absolute neutrophil count (ANC) is < 1500 cells/mm3, and platelet count is < 150 × 103 cells/mm3 [1]. Pancytopenia is considered severe if a patient experiences two or more of the following: hemoglobin < 7 g/dl, ANC < 500 cells/mm3, and platelet count < 50 × 103 cells/mm3. The mechanism underlying pancytopenia mainly involves bone marrow infiltration, bone marrow aplasia, and blood cell destruction that results in peripheral blood leakage [1]. Suppression of bone marrow varies widely in the pediatric population but may occur due to toxins, infection, or malignant cell infiltrates that can lead to hypocellular bone marrow function. Drug-induced pancytopenia is also a rare but secondary cause of bone marrow suppression due to direct bone marrow toxicity, immune-mediated (complement or antibody-mediated) cell destruction, and hapten formation, and directly affects myeloid precursors [2, 3]. An in vitro study of several beta-lactam antibiotics established the presence of well-differentiated myeloid cells and copious granulocyte precursors along with dose-dependent suppression of granulopoiesis [4]. Antibody-mediated hemolytic anemia and thrombocytopenia have also been established in meropenem-treated patients [5, 6]. Several medications can cause pancytopenia including chemotherapeutics, antiepileptics, antidepressants, and antibiotics [3, 5, 7]. A case–control epidemiological surveillance study was conducted over a follow-up period of 78.7 million person-years to assess the incidence of drug-induced agranulocytosis. Around 396 confirmed cases of acute neutropenia were observed, with an overall incidence of 3.5:1 million per year [8]. It was found that agranulocytosis clearly increased the risk of mortality, with a fatality rate of 9.1%. The most common drugs causing agranulocytosis were dipyrone (16%), beta-lactam antibiotics (12.0 %), ticlopidine (11.1%), antithyroid drugs (7.2%), and sulfonamide antibiotics (5.4%) [8].
Meropenem is one of the beta-lactam antibiotics that can cause serious and life-threatening neutropenia. It is a bactericidal broad-spectrum antibiotic with gram-positive, gram-negative, and anaerobic coverage, and is mainly used in the treatment of severe gram-negative infections in neonates including severe sepsis, meningitis, and complicated intra-abdominal infections such as necrotizing enterocolitis (NEC), one of the most common gastrointestinal emergencies and a major cause of morbidity and mortality in preterm neonates. For improved clinical outcomes, early recognition and aggressive management with broad-spectrum or combination antimicrobial agents is most often undertaken to treat NEC [9]. Because of its broad-spectrum activity, meropenem is an agent of great utility [10]. Based on the increasing trends of morbidity and mortality due to multidrug-resistant gram-negative bacterial infections in our neonatal intensive care unit (NICU), and following institutional guidelines, other antibiotics such as vancomycin and colistin are also used [11–13] after infectious disease (ID) consultation. The most common adverse effects of meropenem are constipation or diarrhea, nausea, vomiting, rashes, and diaper-area moniliasis in pediatric patients [14]. Some cases of meropenem-induced neutropenia have been reported [15]. However, no known case of meropenem-induced pancytopenia in neonates has yet been published. Here we report an event of meropenem-induced pancytopenia in a neonate admitted to the NICU of a tertiary-care hospital.
Case presentation
A newborn Pakistani baby was transferred to the intensive care unit due to prematurity, low birth weight, and intrauterine growth retardation. Her birth weight was 0.71 kg and APGAR scores were 3 at 1 minute and 4 at 5 minutes. Delivered by emergency C-section at 29 weeks due to raised blood pressure and fetal distress, she was initially kept on continuous positive airway pressure (CPAP) and given nothing through the mouth, and total parenteral nutrition (TPN) was started. Caffeine was loaded at 20 mg/kg and continued as the standard of care for apnea of prematurity. A prophylactic dose of 1 mg of vitamin K was given. During the first 24 hours, complete blood count (CBC) results were WBC of 18.3 × 103 cells/mm3, ANC of 1244 cells/mm3, platelet count of 166 × 103 cells/mm3, and hemoglobin of 17.8 g/dl. On the second day of life (DOL), ampicillin and gentamicin were started as empirical therapy, and the CBC report showed WBC 4 × 103 cells/mm3, ANC of 760 cells/mm3, platelet count of 152 × 103 cells/mm3, and hemoglobin of 15.9 g/dl. In addition, fluconazole was started as antifungal prophylaxis. The patient was given phototherapy. Chest X-ray and ultrasound of the head were performed, with normal findings. CPAP was tapered to high flow on merit, and blood culture was sent.
On the fourth DOL, the baby developed issues of severe respiratory distress and abdominal distension along with metabolic acidosis. She was intubated and kept on synchronized intermittent mandatory ventilation (SIMV) mode. The CBC results showed ANC of 912 cells/mm3, platelet count of 99 × 103 cells/mm3, and hemoglobin of 12.7 g/dl. Inotropic support was started, and antibiotics were escalated to meropenem 20 mg/kg every 12 hours, vancomycin 10 mg/kg once daily, and colistin at a loading dose of 5 mg/kg with a maintenance dose of 1.5 mg/kg every 12 hours. Blood culture showed no growth. After ID consult, vancomycin was discontinued on the third day and a decision was made to continue meropenem and colistin [11–13] to manage NEC and sepsis.
On the fifth DOL, echocardiogram was performed and showed patent ductus arteriosus (PDA) of 3 mm with severe persistent pulmonary hypertension of the newborn (PPHN). Acetaminophen was started for the next 5 days. On the sixth day of meropenem therapy, the platelet count dropped to 42 × 103 cells/mm3, treated in line with sepsis-associated thrombocytopenia [16], and managed by transfusion of 10 ml/kg platelet units [17]. Meropenem and colistin were discontinued on the eighth day of therapy, and trophic feeding was started. An echocardiogram was repeated on day 11, which showed a closed PDA and moderate PPHN. On the 18th DOL, the child was successfully extubated and kept on high-flow oxygen. There was slow progress in feeding.
On the 22nd DOL, the baby had tachycardia and an episode of 99.7 °F fever. Thus, septic workup was done and showed WBC count of 17.4 × 103 cells/mm3, ANC of 12,632.4 cells/mm3, and platelets of 203 × 103 cells/mm3. C-reactive protein (CRP) was 77 mg/l and renal function was normal (blood urea nitrogen [BUN] of 11 mg/dl and creatinine of 0.2 mg/dl). Meropenem was started in meningitic doses of 40 mg/kg every 8 hours [10] along with vancomycin 15 mg/kg every 12 hours.
In the microbiological investigation, urine and cerebrospinal fluid (CSF) cultures were found to be negative, but the blood culture was positive for Staphylococcus species (not aureus). Blood culture repeated after 48 hours was positive for carbapenem-sensitive Klebsiella pneumoniae. The baby was moved to the isolation room. On the 24th DOL, the baby developed severe thrombocytopenia, with a platelet count of 22 × 103 cells/mm3, managed with the transfusion of 10 ml/kg platelet units [17].
On the 25th DOL, an episode of generalized tonic-clonic fit occurred for which single-dose diazepam and a loading dose of phenobarbitone were given initially and then continued with maintenance doses of phenobarbitone. Due to significant metabolic acidosis and desaturation, the baby was re-intubated. After ID consult, meropenem was continued in meningitic doses and vancomycin was discontinued. SIMV and a central line were placed. TPN was started with nothing per oral status.
Blood gases were monitored, and the baby was extubated after 4 days and switched to CPAP. Phenobarbitone was discontinued after 6 days of therapy, and the baby was seizure-free through the remainder of the hospital stay. All repeat blood cultures were negative for any growth including CSF culture. The ID team was on board and decided to continue meropenem for a total of 14 days post-negative culture in septic doses of 20 mg/kg, and vancomycin was discontinued after 6 days. All repeated blood cultures obtained on the 27th and 30th DOL confirmed no pathogenic growth.
On the 33rd DOL, the CBC report showed WBC of 8.7 × 103 cells/mm3, ANC of 4576 cells/mm3, platelets of 78 × 103 cells/mm3, and hemoglobin of 10.8 g/dl. On the 36th DOL, the CBC report showed WBC of 5.1 × 103 cells/mm3, ANC of 2917 cells/mm3, platelets of 29 × 103 cells/mm3, and hemoglobin of 9.2 g/dl. The baby was managed for thrombocytopenia with platelet transfusion.
On the 37th DOL, hemoglobin dropped to 8.3 g/dl in the evening, and platelet count improved to 63 × 103 cells/mm3, WBC was 4.8 × 103 cells/mm3, and ANC was 1285 cells/mm3. On the 39th DOL, a marked reduction was observed in ANC to 816 cells/mm3, platelets of 38 × 103 cells/mm3, and hemoglobin of 8.3 g/dl, and the baby received blood transfusion to manage it. For constant issues, a hematological consult was taken and a decision was made to manage the baby symptomatically with 10 ml/kg platelet units at a platelet count < 50 [17] and 15 ml/kg packed cell transfusion at hemoglobin < 10 g/dl [18].
On the 40th DOL, meropenem was discontinued 14 days after negative culture (total of 19 days of meropenem therapy). On the same day the platelet count was 34 × 103 cells/mm3, ANC was 818 cells/mm3, and hemoglobin was 10.2 g/dl, and the baby was transfused to manage these issues. After discontinuation of meropenem, the baby was continuously monitored for hematological changes, and low counts persisted for 3 days. Improved ANC of > 1500 cells/mm3 was reported on the fourth day, and platelet count of > 150 × 103 cells/mm3 was reported for the first time on the sixth day of meropenem discontinuation, but hemoglobin was still low (Fig 1). CPAP was tapered gradually to nasal prongs. The peripherally inserted central catheter was removed, and orogastric (OG) tube feeding was commenced. The baby was discharged on the 48th DOL on iron supplements with follow-up monitoring of CBC. Hemoglobin level of 11.2 g/dl was found on the 59th DOL.Fig. 1. Hematological changes and timing of medication during hospitalization
Discussion
Drug-induced pancytopenia is a rare hematological problem in neonatal clinical practices, evaluated based on a complete underlying pathological history, physical examination, and vigilant interpretation of biochemical, radiological, histopathological, and hematological findings [19]. Concerns have been raised about hematological adverse effects of several beta-lactamase inhibitors [8]. This neonatal case documents meropenem-induced pancytopenia and emphasizes cautious laboratory monitoring for patients receiving meropenem therapy.
Sepsis is another known etiology of pancytopenia. Although the neonate in the present case had a blood culture positive for K. pneumoniae, the results of all repeated blood cultures were negative, showing the resolution of sepsis. Van Tuyl et al. [20] also reported a case of a neonate receiving meropenem in meningitic doses of 40 mg/kg/day to treat meropenem-susceptible Enterobacter cloacae in blood culture. The baby developed meropenem-induced neutropenia on the 13th day of therapy, with ANC of 288 cells/mm3. The decision was made to discontinue meropenem on the 19th day of therapy instead of the initially planned 21 days. In the present case, the baby continued to receive meropenem treatment and was managed for hematological problems based on institutional guidelines and culture sensitivity. Initially, hematological changes were not considered as directly meropenem-induced.
Recently published reports also support the notion of carbapenem-induced hematological disorders. A case report by Estella and colleagues [21] described meropenem-induced pancytopenia in a 3-year-old patient at 100 mg/kg given every 8 hours to manage the regrowth of meropenem-sensitive Morganella morganii in CSF cultures. Huang et al. [6] reported a case of meropenem-induced immune thrombocytopenia in a 59-year-old patient, by detecting meropenem-dependent platelet antibodies and platelet count recovery after discontinuation of meropenem. Oka et al. [5] reported the development of severe anemia with clinical signs in a 76-year-old female patient, who received 2 g meropenem per day. On further investigation, they found that a direct antiglobulin test (DAT) was positive for immunoglobulin G (IgG) and C3d, and reported the presence of meropenem-dependent antibodies in the patient’s serum [5].
The absence of drug-dependent antibody testing and bone marrow aspiration prevent us from drawing a firm conclusion regarding the mechanism of meropenem-induced pancytopenia in the present case. However, the hematological findings with the progressive development of thrombocytopenia, anemia, and then neutropenia suggest a possible mechanism of suppression of granulopoiesis or antibody-mediated destruction, as reported in recent studies [5, 6].
During hospitalization, the neonate received other medications, which have been reported to exert hematological effects. The baby initially received ampicillin, gentamicin, and fluconazole, and then received meropenem, colistin, vancomycin, and phenobarbital. However, severe thrombocytopenia developed on the sixth day of the first course of meropenem therapy, when the baby was also on colistin and fluconazole. This issue was resolved when meropenem was discontinued. During the second course of meropenem therapy, the baby again developed severe thrombocytopenia on the third day, while also receiving vancomycin, fluconazole, and phenobarbital. Phenobarbital-induced hematological abnormalities are reported in animal and adult studies [22, 23], and therefore it was discontinued on the sixth day. No seizures were observed but counts did not improve. However, the baby developed severe anemia and neutropenia while receiving fluconazole and meropenem only. After meropenem discontinuation, severe anemia and neutropenia showed a resolving trend for 3 days. Severe neutropenia resolved on the fourth day, and hemoglobin was reported at > 10 g/dl without transfusion on the seventh day of meropenem discontinuation, while fluconazole therapy was continued from the beginning until the 56th DOL, which further confirms the association of meropenem-induced hematological changes in this baby. It was also confirmed that the baby did not experience any additional infection even though she was not discharged on any antibiotic, which correlates with the fast recovery of blood counts after meropenem discontinuation.
Conclusions
In the present neonatal case, the gradual onset of hematological irregularities correlates with the commencement of meropenem therapy, and our observations are also verified by previously published evidence. The follow-up CBC count further established the resolution of pancytopenia after discontinuation of meropenem. Neonatal pancytopenia may lead to serious health complications; therefore, clinicians and pharmacists need to vigilantly monitor CBC counts in this vulnerable population, even when administering meropenem in septic doses for the recommended duration.
Patient perspective
From the perspective of the patient’s father, it was a rare case to have such kind of adverse events in a neonate with the normal treatment regimen. He was shared about all the events and he admired the team for the timely and effectively managing the issues and finally 100% recovery on the follow-ups.
Abbreviations
ANCAbsolute neutrophil count
CBCComplete blood count
DOLDay of life
CPAPContinuous positive airway pressure
TPNTotal parenteral nutrition
SIMVSynchronized intermittent mandatory ventilation
NECNecrotizing enterocolitis
PDAPatent ductus arteriosus
PPHNPersistent pulmonary hypertension of the newborn
CRPC-reactive protein
IDInfectious disease
Publisher's Note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
Acknowledgements
We acknowledge the kind support of Abdul Moiz Hussain for providing technical support in the process of final submission and language review. This study was conducted in the neonatal intensive care unit of Aga Khan University Hospital, Karachi, Pakistan.
Authors’ contributions
GA: Substantial contributions to the conception or design of the work. Performed the study, analysis, or interpretation of patient information. Major contributor in writing the manuscript. KH: Supervised the study and analyzed and interpreted the patient data regarding the hematological changes with therapy. Revised the work critically for important intellectual content. SS: Supervised the study and analyzed and interpreted the patient data regarding the hematological changes with therapy. Final approval of the version published. NM: Wrote the initial draft of the case report. AM: Co-wrote the initial draft. SI: data collection and interpretation. JI: data collection and interpretation. All authors read and approved the final manuscript.
Funding
No source of funding in the research.
Availability of data and materials
All data generated or analyzed during this study are included in the published article. The data sets used and/or analyzed during the current study are available from the corresponding author on reasonable request. Please contact the author for data requests.
Ethics approval and consent to participate
This case report was exempted from formal approval by the Ethical Review Committee, Aga Khan University Karachi, Pakistan.
Consent for publication
Written informed consent was obtained from the patient’s legal guardian(s) for publication of this case report and any accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.
Competing interests
The authors declare that they have no competing interests. | ACETAMINOPHEN, AMPICILLIN, CAFFEINE, COLISTIN, DIAZEPAM, FLUCONAZOLE, MEROPENEM, PHENOBARBITAL, VANCOMYCIN | DrugsGivenReaction | CC BY | 33509295 | 18,915,789 | 2021-01-29 |
Give an alphabetized list of all active substances of drugs taken by the patient who experienced 'Pancytopenia'. | Meropenem-induced pancytopenia in a preterm neonate: a case report.
BACKGROUND
A post-marketing surveillance study has reported an association between meropenem use and the incidence of hematologic abnormalities, including leukopenia, thrombocytopenia, hemolysis, and neutropenia, but the precise incidence in neonates is unknown. Here, we report meropenem-induced pancytopenia in a preterm neonate.
METHODS
A preterm newborn Pakistani received intravenous meropenem 40 mg/kg every 8 hours to treat Klebsiella pneumoniae in blood cultures and suspected meningitis. The baby developed severe thrombocytopenia, with a platelet count of 22 × 103 cells/mm3, low hemoglobin level of 9.7 g/dl, and low absolute neutrophil count (ANC) of 816 cells/mm3 on days 3, 14, and 17 of meropenem therapy, respectively. Based on the blood culture and institutional guidelines, meropenem treatment was continued with monitoring and supportive care for a total of 19 days. After discontinuation of meropenem, the baby was monitored continuously for hematological changes, and low counts persisted for 3 days. ANC improved to > 1500 cells/mm3 on the fourth day, and the platelet count reached > 150 × 103 cells/mm3 for the first time on the seventh day of meropenem discontinuation. All subsequent complete blood count (CBC) reports showed improving trends. The baby was discharged on the 48th day of life (DOL), with follow-up monitoring of CBC. The baby was kept on iron supplements, and hemoglobin level of 11.2 g/dl was observed on the 59th DOL.
CONCLUSIONS
Neonatal pancytopenia may lead to serious health complications; therefore, clinicians and pharmacists need to vigilantly monitor CBC in this vulnerable population, even when administering meropenem in septic doses for the recommended duration.
Background
Pancytopenia is defined as reduced white blood cell (WBC) count, hemoglobin, and platelet count. Pancytopenia occurs when hemoglobin is < 13 g/dl in males and < 12 g/dl in females, absolute neutrophil count (ANC) is < 1500 cells/mm3, and platelet count is < 150 × 103 cells/mm3 [1]. Pancytopenia is considered severe if a patient experiences two or more of the following: hemoglobin < 7 g/dl, ANC < 500 cells/mm3, and platelet count < 50 × 103 cells/mm3. The mechanism underlying pancytopenia mainly involves bone marrow infiltration, bone marrow aplasia, and blood cell destruction that results in peripheral blood leakage [1]. Suppression of bone marrow varies widely in the pediatric population but may occur due to toxins, infection, or malignant cell infiltrates that can lead to hypocellular bone marrow function. Drug-induced pancytopenia is also a rare but secondary cause of bone marrow suppression due to direct bone marrow toxicity, immune-mediated (complement or antibody-mediated) cell destruction, and hapten formation, and directly affects myeloid precursors [2, 3]. An in vitro study of several beta-lactam antibiotics established the presence of well-differentiated myeloid cells and copious granulocyte precursors along with dose-dependent suppression of granulopoiesis [4]. Antibody-mediated hemolytic anemia and thrombocytopenia have also been established in meropenem-treated patients [5, 6]. Several medications can cause pancytopenia including chemotherapeutics, antiepileptics, antidepressants, and antibiotics [3, 5, 7]. A case–control epidemiological surveillance study was conducted over a follow-up period of 78.7 million person-years to assess the incidence of drug-induced agranulocytosis. Around 396 confirmed cases of acute neutropenia were observed, with an overall incidence of 3.5:1 million per year [8]. It was found that agranulocytosis clearly increased the risk of mortality, with a fatality rate of 9.1%. The most common drugs causing agranulocytosis were dipyrone (16%), beta-lactam antibiotics (12.0 %), ticlopidine (11.1%), antithyroid drugs (7.2%), and sulfonamide antibiotics (5.4%) [8].
Meropenem is one of the beta-lactam antibiotics that can cause serious and life-threatening neutropenia. It is a bactericidal broad-spectrum antibiotic with gram-positive, gram-negative, and anaerobic coverage, and is mainly used in the treatment of severe gram-negative infections in neonates including severe sepsis, meningitis, and complicated intra-abdominal infections such as necrotizing enterocolitis (NEC), one of the most common gastrointestinal emergencies and a major cause of morbidity and mortality in preterm neonates. For improved clinical outcomes, early recognition and aggressive management with broad-spectrum or combination antimicrobial agents is most often undertaken to treat NEC [9]. Because of its broad-spectrum activity, meropenem is an agent of great utility [10]. Based on the increasing trends of morbidity and mortality due to multidrug-resistant gram-negative bacterial infections in our neonatal intensive care unit (NICU), and following institutional guidelines, other antibiotics such as vancomycin and colistin are also used [11–13] after infectious disease (ID) consultation. The most common adverse effects of meropenem are constipation or diarrhea, nausea, vomiting, rashes, and diaper-area moniliasis in pediatric patients [14]. Some cases of meropenem-induced neutropenia have been reported [15]. However, no known case of meropenem-induced pancytopenia in neonates has yet been published. Here we report an event of meropenem-induced pancytopenia in a neonate admitted to the NICU of a tertiary-care hospital.
Case presentation
A newborn Pakistani baby was transferred to the intensive care unit due to prematurity, low birth weight, and intrauterine growth retardation. Her birth weight was 0.71 kg and APGAR scores were 3 at 1 minute and 4 at 5 minutes. Delivered by emergency C-section at 29 weeks due to raised blood pressure and fetal distress, she was initially kept on continuous positive airway pressure (CPAP) and given nothing through the mouth, and total parenteral nutrition (TPN) was started. Caffeine was loaded at 20 mg/kg and continued as the standard of care for apnea of prematurity. A prophylactic dose of 1 mg of vitamin K was given. During the first 24 hours, complete blood count (CBC) results were WBC of 18.3 × 103 cells/mm3, ANC of 1244 cells/mm3, platelet count of 166 × 103 cells/mm3, and hemoglobin of 17.8 g/dl. On the second day of life (DOL), ampicillin and gentamicin were started as empirical therapy, and the CBC report showed WBC 4 × 103 cells/mm3, ANC of 760 cells/mm3, platelet count of 152 × 103 cells/mm3, and hemoglobin of 15.9 g/dl. In addition, fluconazole was started as antifungal prophylaxis. The patient was given phototherapy. Chest X-ray and ultrasound of the head were performed, with normal findings. CPAP was tapered to high flow on merit, and blood culture was sent.
On the fourth DOL, the baby developed issues of severe respiratory distress and abdominal distension along with metabolic acidosis. She was intubated and kept on synchronized intermittent mandatory ventilation (SIMV) mode. The CBC results showed ANC of 912 cells/mm3, platelet count of 99 × 103 cells/mm3, and hemoglobin of 12.7 g/dl. Inotropic support was started, and antibiotics were escalated to meropenem 20 mg/kg every 12 hours, vancomycin 10 mg/kg once daily, and colistin at a loading dose of 5 mg/kg with a maintenance dose of 1.5 mg/kg every 12 hours. Blood culture showed no growth. After ID consult, vancomycin was discontinued on the third day and a decision was made to continue meropenem and colistin [11–13] to manage NEC and sepsis.
On the fifth DOL, echocardiogram was performed and showed patent ductus arteriosus (PDA) of 3 mm with severe persistent pulmonary hypertension of the newborn (PPHN). Acetaminophen was started for the next 5 days. On the sixth day of meropenem therapy, the platelet count dropped to 42 × 103 cells/mm3, treated in line with sepsis-associated thrombocytopenia [16], and managed by transfusion of 10 ml/kg platelet units [17]. Meropenem and colistin were discontinued on the eighth day of therapy, and trophic feeding was started. An echocardiogram was repeated on day 11, which showed a closed PDA and moderate PPHN. On the 18th DOL, the child was successfully extubated and kept on high-flow oxygen. There was slow progress in feeding.
On the 22nd DOL, the baby had tachycardia and an episode of 99.7 °F fever. Thus, septic workup was done and showed WBC count of 17.4 × 103 cells/mm3, ANC of 12,632.4 cells/mm3, and platelets of 203 × 103 cells/mm3. C-reactive protein (CRP) was 77 mg/l and renal function was normal (blood urea nitrogen [BUN] of 11 mg/dl and creatinine of 0.2 mg/dl). Meropenem was started in meningitic doses of 40 mg/kg every 8 hours [10] along with vancomycin 15 mg/kg every 12 hours.
In the microbiological investigation, urine and cerebrospinal fluid (CSF) cultures were found to be negative, but the blood culture was positive for Staphylococcus species (not aureus). Blood culture repeated after 48 hours was positive for carbapenem-sensitive Klebsiella pneumoniae. The baby was moved to the isolation room. On the 24th DOL, the baby developed severe thrombocytopenia, with a platelet count of 22 × 103 cells/mm3, managed with the transfusion of 10 ml/kg platelet units [17].
On the 25th DOL, an episode of generalized tonic-clonic fit occurred for which single-dose diazepam and a loading dose of phenobarbitone were given initially and then continued with maintenance doses of phenobarbitone. Due to significant metabolic acidosis and desaturation, the baby was re-intubated. After ID consult, meropenem was continued in meningitic doses and vancomycin was discontinued. SIMV and a central line were placed. TPN was started with nothing per oral status.
Blood gases were monitored, and the baby was extubated after 4 days and switched to CPAP. Phenobarbitone was discontinued after 6 days of therapy, and the baby was seizure-free through the remainder of the hospital stay. All repeat blood cultures were negative for any growth including CSF culture. The ID team was on board and decided to continue meropenem for a total of 14 days post-negative culture in septic doses of 20 mg/kg, and vancomycin was discontinued after 6 days. All repeated blood cultures obtained on the 27th and 30th DOL confirmed no pathogenic growth.
On the 33rd DOL, the CBC report showed WBC of 8.7 × 103 cells/mm3, ANC of 4576 cells/mm3, platelets of 78 × 103 cells/mm3, and hemoglobin of 10.8 g/dl. On the 36th DOL, the CBC report showed WBC of 5.1 × 103 cells/mm3, ANC of 2917 cells/mm3, platelets of 29 × 103 cells/mm3, and hemoglobin of 9.2 g/dl. The baby was managed for thrombocytopenia with platelet transfusion.
On the 37th DOL, hemoglobin dropped to 8.3 g/dl in the evening, and platelet count improved to 63 × 103 cells/mm3, WBC was 4.8 × 103 cells/mm3, and ANC was 1285 cells/mm3. On the 39th DOL, a marked reduction was observed in ANC to 816 cells/mm3, platelets of 38 × 103 cells/mm3, and hemoglobin of 8.3 g/dl, and the baby received blood transfusion to manage it. For constant issues, a hematological consult was taken and a decision was made to manage the baby symptomatically with 10 ml/kg platelet units at a platelet count < 50 [17] and 15 ml/kg packed cell transfusion at hemoglobin < 10 g/dl [18].
On the 40th DOL, meropenem was discontinued 14 days after negative culture (total of 19 days of meropenem therapy). On the same day the platelet count was 34 × 103 cells/mm3, ANC was 818 cells/mm3, and hemoglobin was 10.2 g/dl, and the baby was transfused to manage these issues. After discontinuation of meropenem, the baby was continuously monitored for hematological changes, and low counts persisted for 3 days. Improved ANC of > 1500 cells/mm3 was reported on the fourth day, and platelet count of > 150 × 103 cells/mm3 was reported for the first time on the sixth day of meropenem discontinuation, but hemoglobin was still low (Fig 1). CPAP was tapered gradually to nasal prongs. The peripherally inserted central catheter was removed, and orogastric (OG) tube feeding was commenced. The baby was discharged on the 48th DOL on iron supplements with follow-up monitoring of CBC. Hemoglobin level of 11.2 g/dl was found on the 59th DOL.Fig. 1. Hematological changes and timing of medication during hospitalization
Discussion
Drug-induced pancytopenia is a rare hematological problem in neonatal clinical practices, evaluated based on a complete underlying pathological history, physical examination, and vigilant interpretation of biochemical, radiological, histopathological, and hematological findings [19]. Concerns have been raised about hematological adverse effects of several beta-lactamase inhibitors [8]. This neonatal case documents meropenem-induced pancytopenia and emphasizes cautious laboratory monitoring for patients receiving meropenem therapy.
Sepsis is another known etiology of pancytopenia. Although the neonate in the present case had a blood culture positive for K. pneumoniae, the results of all repeated blood cultures were negative, showing the resolution of sepsis. Van Tuyl et al. [20] also reported a case of a neonate receiving meropenem in meningitic doses of 40 mg/kg/day to treat meropenem-susceptible Enterobacter cloacae in blood culture. The baby developed meropenem-induced neutropenia on the 13th day of therapy, with ANC of 288 cells/mm3. The decision was made to discontinue meropenem on the 19th day of therapy instead of the initially planned 21 days. In the present case, the baby continued to receive meropenem treatment and was managed for hematological problems based on institutional guidelines and culture sensitivity. Initially, hematological changes were not considered as directly meropenem-induced.
Recently published reports also support the notion of carbapenem-induced hematological disorders. A case report by Estella and colleagues [21] described meropenem-induced pancytopenia in a 3-year-old patient at 100 mg/kg given every 8 hours to manage the regrowth of meropenem-sensitive Morganella morganii in CSF cultures. Huang et al. [6] reported a case of meropenem-induced immune thrombocytopenia in a 59-year-old patient, by detecting meropenem-dependent platelet antibodies and platelet count recovery after discontinuation of meropenem. Oka et al. [5] reported the development of severe anemia with clinical signs in a 76-year-old female patient, who received 2 g meropenem per day. On further investigation, they found that a direct antiglobulin test (DAT) was positive for immunoglobulin G (IgG) and C3d, and reported the presence of meropenem-dependent antibodies in the patient’s serum [5].
The absence of drug-dependent antibody testing and bone marrow aspiration prevent us from drawing a firm conclusion regarding the mechanism of meropenem-induced pancytopenia in the present case. However, the hematological findings with the progressive development of thrombocytopenia, anemia, and then neutropenia suggest a possible mechanism of suppression of granulopoiesis or antibody-mediated destruction, as reported in recent studies [5, 6].
During hospitalization, the neonate received other medications, which have been reported to exert hematological effects. The baby initially received ampicillin, gentamicin, and fluconazole, and then received meropenem, colistin, vancomycin, and phenobarbital. However, severe thrombocytopenia developed on the sixth day of the first course of meropenem therapy, when the baby was also on colistin and fluconazole. This issue was resolved when meropenem was discontinued. During the second course of meropenem therapy, the baby again developed severe thrombocytopenia on the third day, while also receiving vancomycin, fluconazole, and phenobarbital. Phenobarbital-induced hematological abnormalities are reported in animal and adult studies [22, 23], and therefore it was discontinued on the sixth day. No seizures were observed but counts did not improve. However, the baby developed severe anemia and neutropenia while receiving fluconazole and meropenem only. After meropenem discontinuation, severe anemia and neutropenia showed a resolving trend for 3 days. Severe neutropenia resolved on the fourth day, and hemoglobin was reported at > 10 g/dl without transfusion on the seventh day of meropenem discontinuation, while fluconazole therapy was continued from the beginning until the 56th DOL, which further confirms the association of meropenem-induced hematological changes in this baby. It was also confirmed that the baby did not experience any additional infection even though she was not discharged on any antibiotic, which correlates with the fast recovery of blood counts after meropenem discontinuation.
Conclusions
In the present neonatal case, the gradual onset of hematological irregularities correlates with the commencement of meropenem therapy, and our observations are also verified by previously published evidence. The follow-up CBC count further established the resolution of pancytopenia after discontinuation of meropenem. Neonatal pancytopenia may lead to serious health complications; therefore, clinicians and pharmacists need to vigilantly monitor CBC counts in this vulnerable population, even when administering meropenem in septic doses for the recommended duration.
Patient perspective
From the perspective of the patient’s father, it was a rare case to have such kind of adverse events in a neonate with the normal treatment regimen. He was shared about all the events and he admired the team for the timely and effectively managing the issues and finally 100% recovery on the follow-ups.
Abbreviations
ANCAbsolute neutrophil count
CBCComplete blood count
DOLDay of life
CPAPContinuous positive airway pressure
TPNTotal parenteral nutrition
SIMVSynchronized intermittent mandatory ventilation
NECNecrotizing enterocolitis
PDAPatent ductus arteriosus
PPHNPersistent pulmonary hypertension of the newborn
CRPC-reactive protein
IDInfectious disease
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Acknowledgements
We acknowledge the kind support of Abdul Moiz Hussain for providing technical support in the process of final submission and language review. This study was conducted in the neonatal intensive care unit of Aga Khan University Hospital, Karachi, Pakistan.
Authors’ contributions
GA: Substantial contributions to the conception or design of the work. Performed the study, analysis, or interpretation of patient information. Major contributor in writing the manuscript. KH: Supervised the study and analyzed and interpreted the patient data regarding the hematological changes with therapy. Revised the work critically for important intellectual content. SS: Supervised the study and analyzed and interpreted the patient data regarding the hematological changes with therapy. Final approval of the version published. NM: Wrote the initial draft of the case report. AM: Co-wrote the initial draft. SI: data collection and interpretation. JI: data collection and interpretation. All authors read and approved the final manuscript.
Funding
No source of funding in the research.
Availability of data and materials
All data generated or analyzed during this study are included in the published article. The data sets used and/or analyzed during the current study are available from the corresponding author on reasonable request. Please contact the author for data requests.
Ethics approval and consent to participate
This case report was exempted from formal approval by the Ethical Review Committee, Aga Khan University Karachi, Pakistan.
Consent for publication
Written informed consent was obtained from the patient’s legal guardian(s) for publication of this case report and any accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.
Competing interests
The authors declare that they have no competing interests. | ACETAMINOPHEN, AMPICILLIN, CAFFEINE, COLISTIN, DIAZEPAM, FLUCONAZOLE, MEROPENEM, PHENOBARBITAL, VANCOMYCIN | DrugsGivenReaction | CC BY | 33509295 | 18,915,789 | 2021-01-29 |
Give an alphabetized list of all active substances of drugs taken by the patient who experienced 'Thrombocytopenia neonatal'. | Meropenem-induced pancytopenia in a preterm neonate: a case report.
BACKGROUND
A post-marketing surveillance study has reported an association between meropenem use and the incidence of hematologic abnormalities, including leukopenia, thrombocytopenia, hemolysis, and neutropenia, but the precise incidence in neonates is unknown. Here, we report meropenem-induced pancytopenia in a preterm neonate.
METHODS
A preterm newborn Pakistani received intravenous meropenem 40 mg/kg every 8 hours to treat Klebsiella pneumoniae in blood cultures and suspected meningitis. The baby developed severe thrombocytopenia, with a platelet count of 22 × 103 cells/mm3, low hemoglobin level of 9.7 g/dl, and low absolute neutrophil count (ANC) of 816 cells/mm3 on days 3, 14, and 17 of meropenem therapy, respectively. Based on the blood culture and institutional guidelines, meropenem treatment was continued with monitoring and supportive care for a total of 19 days. After discontinuation of meropenem, the baby was monitored continuously for hematological changes, and low counts persisted for 3 days. ANC improved to > 1500 cells/mm3 on the fourth day, and the platelet count reached > 150 × 103 cells/mm3 for the first time on the seventh day of meropenem discontinuation. All subsequent complete blood count (CBC) reports showed improving trends. The baby was discharged on the 48th day of life (DOL), with follow-up monitoring of CBC. The baby was kept on iron supplements, and hemoglobin level of 11.2 g/dl was observed on the 59th DOL.
CONCLUSIONS
Neonatal pancytopenia may lead to serious health complications; therefore, clinicians and pharmacists need to vigilantly monitor CBC in this vulnerable population, even when administering meropenem in septic doses for the recommended duration.
Background
Pancytopenia is defined as reduced white blood cell (WBC) count, hemoglobin, and platelet count. Pancytopenia occurs when hemoglobin is < 13 g/dl in males and < 12 g/dl in females, absolute neutrophil count (ANC) is < 1500 cells/mm3, and platelet count is < 150 × 103 cells/mm3 [1]. Pancytopenia is considered severe if a patient experiences two or more of the following: hemoglobin < 7 g/dl, ANC < 500 cells/mm3, and platelet count < 50 × 103 cells/mm3. The mechanism underlying pancytopenia mainly involves bone marrow infiltration, bone marrow aplasia, and blood cell destruction that results in peripheral blood leakage [1]. Suppression of bone marrow varies widely in the pediatric population but may occur due to toxins, infection, or malignant cell infiltrates that can lead to hypocellular bone marrow function. Drug-induced pancytopenia is also a rare but secondary cause of bone marrow suppression due to direct bone marrow toxicity, immune-mediated (complement or antibody-mediated) cell destruction, and hapten formation, and directly affects myeloid precursors [2, 3]. An in vitro study of several beta-lactam antibiotics established the presence of well-differentiated myeloid cells and copious granulocyte precursors along with dose-dependent suppression of granulopoiesis [4]. Antibody-mediated hemolytic anemia and thrombocytopenia have also been established in meropenem-treated patients [5, 6]. Several medications can cause pancytopenia including chemotherapeutics, antiepileptics, antidepressants, and antibiotics [3, 5, 7]. A case–control epidemiological surveillance study was conducted over a follow-up period of 78.7 million person-years to assess the incidence of drug-induced agranulocytosis. Around 396 confirmed cases of acute neutropenia were observed, with an overall incidence of 3.5:1 million per year [8]. It was found that agranulocytosis clearly increased the risk of mortality, with a fatality rate of 9.1%. The most common drugs causing agranulocytosis were dipyrone (16%), beta-lactam antibiotics (12.0 %), ticlopidine (11.1%), antithyroid drugs (7.2%), and sulfonamide antibiotics (5.4%) [8].
Meropenem is one of the beta-lactam antibiotics that can cause serious and life-threatening neutropenia. It is a bactericidal broad-spectrum antibiotic with gram-positive, gram-negative, and anaerobic coverage, and is mainly used in the treatment of severe gram-negative infections in neonates including severe sepsis, meningitis, and complicated intra-abdominal infections such as necrotizing enterocolitis (NEC), one of the most common gastrointestinal emergencies and a major cause of morbidity and mortality in preterm neonates. For improved clinical outcomes, early recognition and aggressive management with broad-spectrum or combination antimicrobial agents is most often undertaken to treat NEC [9]. Because of its broad-spectrum activity, meropenem is an agent of great utility [10]. Based on the increasing trends of morbidity and mortality due to multidrug-resistant gram-negative bacterial infections in our neonatal intensive care unit (NICU), and following institutional guidelines, other antibiotics such as vancomycin and colistin are also used [11–13] after infectious disease (ID) consultation. The most common adverse effects of meropenem are constipation or diarrhea, nausea, vomiting, rashes, and diaper-area moniliasis in pediatric patients [14]. Some cases of meropenem-induced neutropenia have been reported [15]. However, no known case of meropenem-induced pancytopenia in neonates has yet been published. Here we report an event of meropenem-induced pancytopenia in a neonate admitted to the NICU of a tertiary-care hospital.
Case presentation
A newborn Pakistani baby was transferred to the intensive care unit due to prematurity, low birth weight, and intrauterine growth retardation. Her birth weight was 0.71 kg and APGAR scores were 3 at 1 minute and 4 at 5 minutes. Delivered by emergency C-section at 29 weeks due to raised blood pressure and fetal distress, she was initially kept on continuous positive airway pressure (CPAP) and given nothing through the mouth, and total parenteral nutrition (TPN) was started. Caffeine was loaded at 20 mg/kg and continued as the standard of care for apnea of prematurity. A prophylactic dose of 1 mg of vitamin K was given. During the first 24 hours, complete blood count (CBC) results were WBC of 18.3 × 103 cells/mm3, ANC of 1244 cells/mm3, platelet count of 166 × 103 cells/mm3, and hemoglobin of 17.8 g/dl. On the second day of life (DOL), ampicillin and gentamicin were started as empirical therapy, and the CBC report showed WBC 4 × 103 cells/mm3, ANC of 760 cells/mm3, platelet count of 152 × 103 cells/mm3, and hemoglobin of 15.9 g/dl. In addition, fluconazole was started as antifungal prophylaxis. The patient was given phototherapy. Chest X-ray and ultrasound of the head were performed, with normal findings. CPAP was tapered to high flow on merit, and blood culture was sent.
On the fourth DOL, the baby developed issues of severe respiratory distress and abdominal distension along with metabolic acidosis. She was intubated and kept on synchronized intermittent mandatory ventilation (SIMV) mode. The CBC results showed ANC of 912 cells/mm3, platelet count of 99 × 103 cells/mm3, and hemoglobin of 12.7 g/dl. Inotropic support was started, and antibiotics were escalated to meropenem 20 mg/kg every 12 hours, vancomycin 10 mg/kg once daily, and colistin at a loading dose of 5 mg/kg with a maintenance dose of 1.5 mg/kg every 12 hours. Blood culture showed no growth. After ID consult, vancomycin was discontinued on the third day and a decision was made to continue meropenem and colistin [11–13] to manage NEC and sepsis.
On the fifth DOL, echocardiogram was performed and showed patent ductus arteriosus (PDA) of 3 mm with severe persistent pulmonary hypertension of the newborn (PPHN). Acetaminophen was started for the next 5 days. On the sixth day of meropenem therapy, the platelet count dropped to 42 × 103 cells/mm3, treated in line with sepsis-associated thrombocytopenia [16], and managed by transfusion of 10 ml/kg platelet units [17]. Meropenem and colistin were discontinued on the eighth day of therapy, and trophic feeding was started. An echocardiogram was repeated on day 11, which showed a closed PDA and moderate PPHN. On the 18th DOL, the child was successfully extubated and kept on high-flow oxygen. There was slow progress in feeding.
On the 22nd DOL, the baby had tachycardia and an episode of 99.7 °F fever. Thus, septic workup was done and showed WBC count of 17.4 × 103 cells/mm3, ANC of 12,632.4 cells/mm3, and platelets of 203 × 103 cells/mm3. C-reactive protein (CRP) was 77 mg/l and renal function was normal (blood urea nitrogen [BUN] of 11 mg/dl and creatinine of 0.2 mg/dl). Meropenem was started in meningitic doses of 40 mg/kg every 8 hours [10] along with vancomycin 15 mg/kg every 12 hours.
In the microbiological investigation, urine and cerebrospinal fluid (CSF) cultures were found to be negative, but the blood culture was positive for Staphylococcus species (not aureus). Blood culture repeated after 48 hours was positive for carbapenem-sensitive Klebsiella pneumoniae. The baby was moved to the isolation room. On the 24th DOL, the baby developed severe thrombocytopenia, with a platelet count of 22 × 103 cells/mm3, managed with the transfusion of 10 ml/kg platelet units [17].
On the 25th DOL, an episode of generalized tonic-clonic fit occurred for which single-dose diazepam and a loading dose of phenobarbitone were given initially and then continued with maintenance doses of phenobarbitone. Due to significant metabolic acidosis and desaturation, the baby was re-intubated. After ID consult, meropenem was continued in meningitic doses and vancomycin was discontinued. SIMV and a central line were placed. TPN was started with nothing per oral status.
Blood gases were monitored, and the baby was extubated after 4 days and switched to CPAP. Phenobarbitone was discontinued after 6 days of therapy, and the baby was seizure-free through the remainder of the hospital stay. All repeat blood cultures were negative for any growth including CSF culture. The ID team was on board and decided to continue meropenem for a total of 14 days post-negative culture in septic doses of 20 mg/kg, and vancomycin was discontinued after 6 days. All repeated blood cultures obtained on the 27th and 30th DOL confirmed no pathogenic growth.
On the 33rd DOL, the CBC report showed WBC of 8.7 × 103 cells/mm3, ANC of 4576 cells/mm3, platelets of 78 × 103 cells/mm3, and hemoglobin of 10.8 g/dl. On the 36th DOL, the CBC report showed WBC of 5.1 × 103 cells/mm3, ANC of 2917 cells/mm3, platelets of 29 × 103 cells/mm3, and hemoglobin of 9.2 g/dl. The baby was managed for thrombocytopenia with platelet transfusion.
On the 37th DOL, hemoglobin dropped to 8.3 g/dl in the evening, and platelet count improved to 63 × 103 cells/mm3, WBC was 4.8 × 103 cells/mm3, and ANC was 1285 cells/mm3. On the 39th DOL, a marked reduction was observed in ANC to 816 cells/mm3, platelets of 38 × 103 cells/mm3, and hemoglobin of 8.3 g/dl, and the baby received blood transfusion to manage it. For constant issues, a hematological consult was taken and a decision was made to manage the baby symptomatically with 10 ml/kg platelet units at a platelet count < 50 [17] and 15 ml/kg packed cell transfusion at hemoglobin < 10 g/dl [18].
On the 40th DOL, meropenem was discontinued 14 days after negative culture (total of 19 days of meropenem therapy). On the same day the platelet count was 34 × 103 cells/mm3, ANC was 818 cells/mm3, and hemoglobin was 10.2 g/dl, and the baby was transfused to manage these issues. After discontinuation of meropenem, the baby was continuously monitored for hematological changes, and low counts persisted for 3 days. Improved ANC of > 1500 cells/mm3 was reported on the fourth day, and platelet count of > 150 × 103 cells/mm3 was reported for the first time on the sixth day of meropenem discontinuation, but hemoglobin was still low (Fig 1). CPAP was tapered gradually to nasal prongs. The peripherally inserted central catheter was removed, and orogastric (OG) tube feeding was commenced. The baby was discharged on the 48th DOL on iron supplements with follow-up monitoring of CBC. Hemoglobin level of 11.2 g/dl was found on the 59th DOL.Fig. 1. Hematological changes and timing of medication during hospitalization
Discussion
Drug-induced pancytopenia is a rare hematological problem in neonatal clinical practices, evaluated based on a complete underlying pathological history, physical examination, and vigilant interpretation of biochemical, radiological, histopathological, and hematological findings [19]. Concerns have been raised about hematological adverse effects of several beta-lactamase inhibitors [8]. This neonatal case documents meropenem-induced pancytopenia and emphasizes cautious laboratory monitoring for patients receiving meropenem therapy.
Sepsis is another known etiology of pancytopenia. Although the neonate in the present case had a blood culture positive for K. pneumoniae, the results of all repeated blood cultures were negative, showing the resolution of sepsis. Van Tuyl et al. [20] also reported a case of a neonate receiving meropenem in meningitic doses of 40 mg/kg/day to treat meropenem-susceptible Enterobacter cloacae in blood culture. The baby developed meropenem-induced neutropenia on the 13th day of therapy, with ANC of 288 cells/mm3. The decision was made to discontinue meropenem on the 19th day of therapy instead of the initially planned 21 days. In the present case, the baby continued to receive meropenem treatment and was managed for hematological problems based on institutional guidelines and culture sensitivity. Initially, hematological changes were not considered as directly meropenem-induced.
Recently published reports also support the notion of carbapenem-induced hematological disorders. A case report by Estella and colleagues [21] described meropenem-induced pancytopenia in a 3-year-old patient at 100 mg/kg given every 8 hours to manage the regrowth of meropenem-sensitive Morganella morganii in CSF cultures. Huang et al. [6] reported a case of meropenem-induced immune thrombocytopenia in a 59-year-old patient, by detecting meropenem-dependent platelet antibodies and platelet count recovery after discontinuation of meropenem. Oka et al. [5] reported the development of severe anemia with clinical signs in a 76-year-old female patient, who received 2 g meropenem per day. On further investigation, they found that a direct antiglobulin test (DAT) was positive for immunoglobulin G (IgG) and C3d, and reported the presence of meropenem-dependent antibodies in the patient’s serum [5].
The absence of drug-dependent antibody testing and bone marrow aspiration prevent us from drawing a firm conclusion regarding the mechanism of meropenem-induced pancytopenia in the present case. However, the hematological findings with the progressive development of thrombocytopenia, anemia, and then neutropenia suggest a possible mechanism of suppression of granulopoiesis or antibody-mediated destruction, as reported in recent studies [5, 6].
During hospitalization, the neonate received other medications, which have been reported to exert hematological effects. The baby initially received ampicillin, gentamicin, and fluconazole, and then received meropenem, colistin, vancomycin, and phenobarbital. However, severe thrombocytopenia developed on the sixth day of the first course of meropenem therapy, when the baby was also on colistin and fluconazole. This issue was resolved when meropenem was discontinued. During the second course of meropenem therapy, the baby again developed severe thrombocytopenia on the third day, while also receiving vancomycin, fluconazole, and phenobarbital. Phenobarbital-induced hematological abnormalities are reported in animal and adult studies [22, 23], and therefore it was discontinued on the sixth day. No seizures were observed but counts did not improve. However, the baby developed severe anemia and neutropenia while receiving fluconazole and meropenem only. After meropenem discontinuation, severe anemia and neutropenia showed a resolving trend for 3 days. Severe neutropenia resolved on the fourth day, and hemoglobin was reported at > 10 g/dl without transfusion on the seventh day of meropenem discontinuation, while fluconazole therapy was continued from the beginning until the 56th DOL, which further confirms the association of meropenem-induced hematological changes in this baby. It was also confirmed that the baby did not experience any additional infection even though she was not discharged on any antibiotic, which correlates with the fast recovery of blood counts after meropenem discontinuation.
Conclusions
In the present neonatal case, the gradual onset of hematological irregularities correlates with the commencement of meropenem therapy, and our observations are also verified by previously published evidence. The follow-up CBC count further established the resolution of pancytopenia after discontinuation of meropenem. Neonatal pancytopenia may lead to serious health complications; therefore, clinicians and pharmacists need to vigilantly monitor CBC counts in this vulnerable population, even when administering meropenem in septic doses for the recommended duration.
Patient perspective
From the perspective of the patient’s father, it was a rare case to have such kind of adverse events in a neonate with the normal treatment regimen. He was shared about all the events and he admired the team for the timely and effectively managing the issues and finally 100% recovery on the follow-ups.
Abbreviations
ANCAbsolute neutrophil count
CBCComplete blood count
DOLDay of life
CPAPContinuous positive airway pressure
TPNTotal parenteral nutrition
SIMVSynchronized intermittent mandatory ventilation
NECNecrotizing enterocolitis
PDAPatent ductus arteriosus
PPHNPersistent pulmonary hypertension of the newborn
CRPC-reactive protein
IDInfectious disease
Publisher's Note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
Acknowledgements
We acknowledge the kind support of Abdul Moiz Hussain for providing technical support in the process of final submission and language review. This study was conducted in the neonatal intensive care unit of Aga Khan University Hospital, Karachi, Pakistan.
Authors’ contributions
GA: Substantial contributions to the conception or design of the work. Performed the study, analysis, or interpretation of patient information. Major contributor in writing the manuscript. KH: Supervised the study and analyzed and interpreted the patient data regarding the hematological changes with therapy. Revised the work critically for important intellectual content. SS: Supervised the study and analyzed and interpreted the patient data regarding the hematological changes with therapy. Final approval of the version published. NM: Wrote the initial draft of the case report. AM: Co-wrote the initial draft. SI: data collection and interpretation. JI: data collection and interpretation. All authors read and approved the final manuscript.
Funding
No source of funding in the research.
Availability of data and materials
All data generated or analyzed during this study are included in the published article. The data sets used and/or analyzed during the current study are available from the corresponding author on reasonable request. Please contact the author for data requests.
Ethics approval and consent to participate
This case report was exempted from formal approval by the Ethical Review Committee, Aga Khan University Karachi, Pakistan.
Consent for publication
Written informed consent was obtained from the patient’s legal guardian(s) for publication of this case report and any accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.
Competing interests
The authors declare that they have no competing interests. | ACETAMINOPHEN, AMPICILLIN, CAFFEINE, COLISTIN, DIAZEPAM, FLUCONAZOLE, MEROPENEM, PHENOBARBITAL, VANCOMYCIN | DrugsGivenReaction | CC BY | 33509295 | 18,915,789 | 2021-01-29 |
What was the dosage of drug 'ACETAMINOPHEN'? | Meropenem-induced pancytopenia in a preterm neonate: a case report.
BACKGROUND
A post-marketing surveillance study has reported an association between meropenem use and the incidence of hematologic abnormalities, including leukopenia, thrombocytopenia, hemolysis, and neutropenia, but the precise incidence in neonates is unknown. Here, we report meropenem-induced pancytopenia in a preterm neonate.
METHODS
A preterm newborn Pakistani received intravenous meropenem 40 mg/kg every 8 hours to treat Klebsiella pneumoniae in blood cultures and suspected meningitis. The baby developed severe thrombocytopenia, with a platelet count of 22 × 103 cells/mm3, low hemoglobin level of 9.7 g/dl, and low absolute neutrophil count (ANC) of 816 cells/mm3 on days 3, 14, and 17 of meropenem therapy, respectively. Based on the blood culture and institutional guidelines, meropenem treatment was continued with monitoring and supportive care for a total of 19 days. After discontinuation of meropenem, the baby was monitored continuously for hematological changes, and low counts persisted for 3 days. ANC improved to > 1500 cells/mm3 on the fourth day, and the platelet count reached > 150 × 103 cells/mm3 for the first time on the seventh day of meropenem discontinuation. All subsequent complete blood count (CBC) reports showed improving trends. The baby was discharged on the 48th day of life (DOL), with follow-up monitoring of CBC. The baby was kept on iron supplements, and hemoglobin level of 11.2 g/dl was observed on the 59th DOL.
CONCLUSIONS
Neonatal pancytopenia may lead to serious health complications; therefore, clinicians and pharmacists need to vigilantly monitor CBC in this vulnerable population, even when administering meropenem in septic doses for the recommended duration.
Background
Pancytopenia is defined as reduced white blood cell (WBC) count, hemoglobin, and platelet count. Pancytopenia occurs when hemoglobin is < 13 g/dl in males and < 12 g/dl in females, absolute neutrophil count (ANC) is < 1500 cells/mm3, and platelet count is < 150 × 103 cells/mm3 [1]. Pancytopenia is considered severe if a patient experiences two or more of the following: hemoglobin < 7 g/dl, ANC < 500 cells/mm3, and platelet count < 50 × 103 cells/mm3. The mechanism underlying pancytopenia mainly involves bone marrow infiltration, bone marrow aplasia, and blood cell destruction that results in peripheral blood leakage [1]. Suppression of bone marrow varies widely in the pediatric population but may occur due to toxins, infection, or malignant cell infiltrates that can lead to hypocellular bone marrow function. Drug-induced pancytopenia is also a rare but secondary cause of bone marrow suppression due to direct bone marrow toxicity, immune-mediated (complement or antibody-mediated) cell destruction, and hapten formation, and directly affects myeloid precursors [2, 3]. An in vitro study of several beta-lactam antibiotics established the presence of well-differentiated myeloid cells and copious granulocyte precursors along with dose-dependent suppression of granulopoiesis [4]. Antibody-mediated hemolytic anemia and thrombocytopenia have also been established in meropenem-treated patients [5, 6]. Several medications can cause pancytopenia including chemotherapeutics, antiepileptics, antidepressants, and antibiotics [3, 5, 7]. A case–control epidemiological surveillance study was conducted over a follow-up period of 78.7 million person-years to assess the incidence of drug-induced agranulocytosis. Around 396 confirmed cases of acute neutropenia were observed, with an overall incidence of 3.5:1 million per year [8]. It was found that agranulocytosis clearly increased the risk of mortality, with a fatality rate of 9.1%. The most common drugs causing agranulocytosis were dipyrone (16%), beta-lactam antibiotics (12.0 %), ticlopidine (11.1%), antithyroid drugs (7.2%), and sulfonamide antibiotics (5.4%) [8].
Meropenem is one of the beta-lactam antibiotics that can cause serious and life-threatening neutropenia. It is a bactericidal broad-spectrum antibiotic with gram-positive, gram-negative, and anaerobic coverage, and is mainly used in the treatment of severe gram-negative infections in neonates including severe sepsis, meningitis, and complicated intra-abdominal infections such as necrotizing enterocolitis (NEC), one of the most common gastrointestinal emergencies and a major cause of morbidity and mortality in preterm neonates. For improved clinical outcomes, early recognition and aggressive management with broad-spectrum or combination antimicrobial agents is most often undertaken to treat NEC [9]. Because of its broad-spectrum activity, meropenem is an agent of great utility [10]. Based on the increasing trends of morbidity and mortality due to multidrug-resistant gram-negative bacterial infections in our neonatal intensive care unit (NICU), and following institutional guidelines, other antibiotics such as vancomycin and colistin are also used [11–13] after infectious disease (ID) consultation. The most common adverse effects of meropenem are constipation or diarrhea, nausea, vomiting, rashes, and diaper-area moniliasis in pediatric patients [14]. Some cases of meropenem-induced neutropenia have been reported [15]. However, no known case of meropenem-induced pancytopenia in neonates has yet been published. Here we report an event of meropenem-induced pancytopenia in a neonate admitted to the NICU of a tertiary-care hospital.
Case presentation
A newborn Pakistani baby was transferred to the intensive care unit due to prematurity, low birth weight, and intrauterine growth retardation. Her birth weight was 0.71 kg and APGAR scores were 3 at 1 minute and 4 at 5 minutes. Delivered by emergency C-section at 29 weeks due to raised blood pressure and fetal distress, she was initially kept on continuous positive airway pressure (CPAP) and given nothing through the mouth, and total parenteral nutrition (TPN) was started. Caffeine was loaded at 20 mg/kg and continued as the standard of care for apnea of prematurity. A prophylactic dose of 1 mg of vitamin K was given. During the first 24 hours, complete blood count (CBC) results were WBC of 18.3 × 103 cells/mm3, ANC of 1244 cells/mm3, platelet count of 166 × 103 cells/mm3, and hemoglobin of 17.8 g/dl. On the second day of life (DOL), ampicillin and gentamicin were started as empirical therapy, and the CBC report showed WBC 4 × 103 cells/mm3, ANC of 760 cells/mm3, platelet count of 152 × 103 cells/mm3, and hemoglobin of 15.9 g/dl. In addition, fluconazole was started as antifungal prophylaxis. The patient was given phototherapy. Chest X-ray and ultrasound of the head were performed, with normal findings. CPAP was tapered to high flow on merit, and blood culture was sent.
On the fourth DOL, the baby developed issues of severe respiratory distress and abdominal distension along with metabolic acidosis. She was intubated and kept on synchronized intermittent mandatory ventilation (SIMV) mode. The CBC results showed ANC of 912 cells/mm3, platelet count of 99 × 103 cells/mm3, and hemoglobin of 12.7 g/dl. Inotropic support was started, and antibiotics were escalated to meropenem 20 mg/kg every 12 hours, vancomycin 10 mg/kg once daily, and colistin at a loading dose of 5 mg/kg with a maintenance dose of 1.5 mg/kg every 12 hours. Blood culture showed no growth. After ID consult, vancomycin was discontinued on the third day and a decision was made to continue meropenem and colistin [11–13] to manage NEC and sepsis.
On the fifth DOL, echocardiogram was performed and showed patent ductus arteriosus (PDA) of 3 mm with severe persistent pulmonary hypertension of the newborn (PPHN). Acetaminophen was started for the next 5 days. On the sixth day of meropenem therapy, the platelet count dropped to 42 × 103 cells/mm3, treated in line with sepsis-associated thrombocytopenia [16], and managed by transfusion of 10 ml/kg platelet units [17]. Meropenem and colistin were discontinued on the eighth day of therapy, and trophic feeding was started. An echocardiogram was repeated on day 11, which showed a closed PDA and moderate PPHN. On the 18th DOL, the child was successfully extubated and kept on high-flow oxygen. There was slow progress in feeding.
On the 22nd DOL, the baby had tachycardia and an episode of 99.7 °F fever. Thus, septic workup was done and showed WBC count of 17.4 × 103 cells/mm3, ANC of 12,632.4 cells/mm3, and platelets of 203 × 103 cells/mm3. C-reactive protein (CRP) was 77 mg/l and renal function was normal (blood urea nitrogen [BUN] of 11 mg/dl and creatinine of 0.2 mg/dl). Meropenem was started in meningitic doses of 40 mg/kg every 8 hours [10] along with vancomycin 15 mg/kg every 12 hours.
In the microbiological investigation, urine and cerebrospinal fluid (CSF) cultures were found to be negative, but the blood culture was positive for Staphylococcus species (not aureus). Blood culture repeated after 48 hours was positive for carbapenem-sensitive Klebsiella pneumoniae. The baby was moved to the isolation room. On the 24th DOL, the baby developed severe thrombocytopenia, with a platelet count of 22 × 103 cells/mm3, managed with the transfusion of 10 ml/kg platelet units [17].
On the 25th DOL, an episode of generalized tonic-clonic fit occurred for which single-dose diazepam and a loading dose of phenobarbitone were given initially and then continued with maintenance doses of phenobarbitone. Due to significant metabolic acidosis and desaturation, the baby was re-intubated. After ID consult, meropenem was continued in meningitic doses and vancomycin was discontinued. SIMV and a central line were placed. TPN was started with nothing per oral status.
Blood gases were monitored, and the baby was extubated after 4 days and switched to CPAP. Phenobarbitone was discontinued after 6 days of therapy, and the baby was seizure-free through the remainder of the hospital stay. All repeat blood cultures were negative for any growth including CSF culture. The ID team was on board and decided to continue meropenem for a total of 14 days post-negative culture in septic doses of 20 mg/kg, and vancomycin was discontinued after 6 days. All repeated blood cultures obtained on the 27th and 30th DOL confirmed no pathogenic growth.
On the 33rd DOL, the CBC report showed WBC of 8.7 × 103 cells/mm3, ANC of 4576 cells/mm3, platelets of 78 × 103 cells/mm3, and hemoglobin of 10.8 g/dl. On the 36th DOL, the CBC report showed WBC of 5.1 × 103 cells/mm3, ANC of 2917 cells/mm3, platelets of 29 × 103 cells/mm3, and hemoglobin of 9.2 g/dl. The baby was managed for thrombocytopenia with platelet transfusion.
On the 37th DOL, hemoglobin dropped to 8.3 g/dl in the evening, and platelet count improved to 63 × 103 cells/mm3, WBC was 4.8 × 103 cells/mm3, and ANC was 1285 cells/mm3. On the 39th DOL, a marked reduction was observed in ANC to 816 cells/mm3, platelets of 38 × 103 cells/mm3, and hemoglobin of 8.3 g/dl, and the baby received blood transfusion to manage it. For constant issues, a hematological consult was taken and a decision was made to manage the baby symptomatically with 10 ml/kg platelet units at a platelet count < 50 [17] and 15 ml/kg packed cell transfusion at hemoglobin < 10 g/dl [18].
On the 40th DOL, meropenem was discontinued 14 days after negative culture (total of 19 days of meropenem therapy). On the same day the platelet count was 34 × 103 cells/mm3, ANC was 818 cells/mm3, and hemoglobin was 10.2 g/dl, and the baby was transfused to manage these issues. After discontinuation of meropenem, the baby was continuously monitored for hematological changes, and low counts persisted for 3 days. Improved ANC of > 1500 cells/mm3 was reported on the fourth day, and platelet count of > 150 × 103 cells/mm3 was reported for the first time on the sixth day of meropenem discontinuation, but hemoglobin was still low (Fig 1). CPAP was tapered gradually to nasal prongs. The peripherally inserted central catheter was removed, and orogastric (OG) tube feeding was commenced. The baby was discharged on the 48th DOL on iron supplements with follow-up monitoring of CBC. Hemoglobin level of 11.2 g/dl was found on the 59th DOL.Fig. 1. Hematological changes and timing of medication during hospitalization
Discussion
Drug-induced pancytopenia is a rare hematological problem in neonatal clinical practices, evaluated based on a complete underlying pathological history, physical examination, and vigilant interpretation of biochemical, radiological, histopathological, and hematological findings [19]. Concerns have been raised about hematological adverse effects of several beta-lactamase inhibitors [8]. This neonatal case documents meropenem-induced pancytopenia and emphasizes cautious laboratory monitoring for patients receiving meropenem therapy.
Sepsis is another known etiology of pancytopenia. Although the neonate in the present case had a blood culture positive for K. pneumoniae, the results of all repeated blood cultures were negative, showing the resolution of sepsis. Van Tuyl et al. [20] also reported a case of a neonate receiving meropenem in meningitic doses of 40 mg/kg/day to treat meropenem-susceptible Enterobacter cloacae in blood culture. The baby developed meropenem-induced neutropenia on the 13th day of therapy, with ANC of 288 cells/mm3. The decision was made to discontinue meropenem on the 19th day of therapy instead of the initially planned 21 days. In the present case, the baby continued to receive meropenem treatment and was managed for hematological problems based on institutional guidelines and culture sensitivity. Initially, hematological changes were not considered as directly meropenem-induced.
Recently published reports also support the notion of carbapenem-induced hematological disorders. A case report by Estella and colleagues [21] described meropenem-induced pancytopenia in a 3-year-old patient at 100 mg/kg given every 8 hours to manage the regrowth of meropenem-sensitive Morganella morganii in CSF cultures. Huang et al. [6] reported a case of meropenem-induced immune thrombocytopenia in a 59-year-old patient, by detecting meropenem-dependent platelet antibodies and platelet count recovery after discontinuation of meropenem. Oka et al. [5] reported the development of severe anemia with clinical signs in a 76-year-old female patient, who received 2 g meropenem per day. On further investigation, they found that a direct antiglobulin test (DAT) was positive for immunoglobulin G (IgG) and C3d, and reported the presence of meropenem-dependent antibodies in the patient’s serum [5].
The absence of drug-dependent antibody testing and bone marrow aspiration prevent us from drawing a firm conclusion regarding the mechanism of meropenem-induced pancytopenia in the present case. However, the hematological findings with the progressive development of thrombocytopenia, anemia, and then neutropenia suggest a possible mechanism of suppression of granulopoiesis or antibody-mediated destruction, as reported in recent studies [5, 6].
During hospitalization, the neonate received other medications, which have been reported to exert hematological effects. The baby initially received ampicillin, gentamicin, and fluconazole, and then received meropenem, colistin, vancomycin, and phenobarbital. However, severe thrombocytopenia developed on the sixth day of the first course of meropenem therapy, when the baby was also on colistin and fluconazole. This issue was resolved when meropenem was discontinued. During the second course of meropenem therapy, the baby again developed severe thrombocytopenia on the third day, while also receiving vancomycin, fluconazole, and phenobarbital. Phenobarbital-induced hematological abnormalities are reported in animal and adult studies [22, 23], and therefore it was discontinued on the sixth day. No seizures were observed but counts did not improve. However, the baby developed severe anemia and neutropenia while receiving fluconazole and meropenem only. After meropenem discontinuation, severe anemia and neutropenia showed a resolving trend for 3 days. Severe neutropenia resolved on the fourth day, and hemoglobin was reported at > 10 g/dl without transfusion on the seventh day of meropenem discontinuation, while fluconazole therapy was continued from the beginning until the 56th DOL, which further confirms the association of meropenem-induced hematological changes in this baby. It was also confirmed that the baby did not experience any additional infection even though she was not discharged on any antibiotic, which correlates with the fast recovery of blood counts after meropenem discontinuation.
Conclusions
In the present neonatal case, the gradual onset of hematological irregularities correlates with the commencement of meropenem therapy, and our observations are also verified by previously published evidence. The follow-up CBC count further established the resolution of pancytopenia after discontinuation of meropenem. Neonatal pancytopenia may lead to serious health complications; therefore, clinicians and pharmacists need to vigilantly monitor CBC counts in this vulnerable population, even when administering meropenem in septic doses for the recommended duration.
Patient perspective
From the perspective of the patient’s father, it was a rare case to have such kind of adverse events in a neonate with the normal treatment regimen. He was shared about all the events and he admired the team for the timely and effectively managing the issues and finally 100% recovery on the follow-ups.
Abbreviations
ANCAbsolute neutrophil count
CBCComplete blood count
DOLDay of life
CPAPContinuous positive airway pressure
TPNTotal parenteral nutrition
SIMVSynchronized intermittent mandatory ventilation
NECNecrotizing enterocolitis
PDAPatent ductus arteriosus
PPHNPersistent pulmonary hypertension of the newborn
CRPC-reactive protein
IDInfectious disease
Publisher's Note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
Acknowledgements
We acknowledge the kind support of Abdul Moiz Hussain for providing technical support in the process of final submission and language review. This study was conducted in the neonatal intensive care unit of Aga Khan University Hospital, Karachi, Pakistan.
Authors’ contributions
GA: Substantial contributions to the conception or design of the work. Performed the study, analysis, or interpretation of patient information. Major contributor in writing the manuscript. KH: Supervised the study and analyzed and interpreted the patient data regarding the hematological changes with therapy. Revised the work critically for important intellectual content. SS: Supervised the study and analyzed and interpreted the patient data regarding the hematological changes with therapy. Final approval of the version published. NM: Wrote the initial draft of the case report. AM: Co-wrote the initial draft. SI: data collection and interpretation. JI: data collection and interpretation. All authors read and approved the final manuscript.
Funding
No source of funding in the research.
Availability of data and materials
All data generated or analyzed during this study are included in the published article. The data sets used and/or analyzed during the current study are available from the corresponding author on reasonable request. Please contact the author for data requests.
Ethics approval and consent to participate
This case report was exempted from formal approval by the Ethical Review Committee, Aga Khan University Karachi, Pakistan.
Consent for publication
Written informed consent was obtained from the patient’s legal guardian(s) for publication of this case report and any accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.
Competing interests
The authors declare that they have no competing interests. | UNK, FROM THE FIFTH DOL | DrugDosageText | CC BY | 33509295 | 18,915,789 | 2021-01-29 |
What was the dosage of drug 'AMPICILLIN'? | Meropenem-induced pancytopenia in a preterm neonate: a case report.
BACKGROUND
A post-marketing surveillance study has reported an association between meropenem use and the incidence of hematologic abnormalities, including leukopenia, thrombocytopenia, hemolysis, and neutropenia, but the precise incidence in neonates is unknown. Here, we report meropenem-induced pancytopenia in a preterm neonate.
METHODS
A preterm newborn Pakistani received intravenous meropenem 40 mg/kg every 8 hours to treat Klebsiella pneumoniae in blood cultures and suspected meningitis. The baby developed severe thrombocytopenia, with a platelet count of 22 × 103 cells/mm3, low hemoglobin level of 9.7 g/dl, and low absolute neutrophil count (ANC) of 816 cells/mm3 on days 3, 14, and 17 of meropenem therapy, respectively. Based on the blood culture and institutional guidelines, meropenem treatment was continued with monitoring and supportive care for a total of 19 days. After discontinuation of meropenem, the baby was monitored continuously for hematological changes, and low counts persisted for 3 days. ANC improved to > 1500 cells/mm3 on the fourth day, and the platelet count reached > 150 × 103 cells/mm3 for the first time on the seventh day of meropenem discontinuation. All subsequent complete blood count (CBC) reports showed improving trends. The baby was discharged on the 48th day of life (DOL), with follow-up monitoring of CBC. The baby was kept on iron supplements, and hemoglobin level of 11.2 g/dl was observed on the 59th DOL.
CONCLUSIONS
Neonatal pancytopenia may lead to serious health complications; therefore, clinicians and pharmacists need to vigilantly monitor CBC in this vulnerable population, even when administering meropenem in septic doses for the recommended duration.
Background
Pancytopenia is defined as reduced white blood cell (WBC) count, hemoglobin, and platelet count. Pancytopenia occurs when hemoglobin is < 13 g/dl in males and < 12 g/dl in females, absolute neutrophil count (ANC) is < 1500 cells/mm3, and platelet count is < 150 × 103 cells/mm3 [1]. Pancytopenia is considered severe if a patient experiences two or more of the following: hemoglobin < 7 g/dl, ANC < 500 cells/mm3, and platelet count < 50 × 103 cells/mm3. The mechanism underlying pancytopenia mainly involves bone marrow infiltration, bone marrow aplasia, and blood cell destruction that results in peripheral blood leakage [1]. Suppression of bone marrow varies widely in the pediatric population but may occur due to toxins, infection, or malignant cell infiltrates that can lead to hypocellular bone marrow function. Drug-induced pancytopenia is also a rare but secondary cause of bone marrow suppression due to direct bone marrow toxicity, immune-mediated (complement or antibody-mediated) cell destruction, and hapten formation, and directly affects myeloid precursors [2, 3]. An in vitro study of several beta-lactam antibiotics established the presence of well-differentiated myeloid cells and copious granulocyte precursors along with dose-dependent suppression of granulopoiesis [4]. Antibody-mediated hemolytic anemia and thrombocytopenia have also been established in meropenem-treated patients [5, 6]. Several medications can cause pancytopenia including chemotherapeutics, antiepileptics, antidepressants, and antibiotics [3, 5, 7]. A case–control epidemiological surveillance study was conducted over a follow-up period of 78.7 million person-years to assess the incidence of drug-induced agranulocytosis. Around 396 confirmed cases of acute neutropenia were observed, with an overall incidence of 3.5:1 million per year [8]. It was found that agranulocytosis clearly increased the risk of mortality, with a fatality rate of 9.1%. The most common drugs causing agranulocytosis were dipyrone (16%), beta-lactam antibiotics (12.0 %), ticlopidine (11.1%), antithyroid drugs (7.2%), and sulfonamide antibiotics (5.4%) [8].
Meropenem is one of the beta-lactam antibiotics that can cause serious and life-threatening neutropenia. It is a bactericidal broad-spectrum antibiotic with gram-positive, gram-negative, and anaerobic coverage, and is mainly used in the treatment of severe gram-negative infections in neonates including severe sepsis, meningitis, and complicated intra-abdominal infections such as necrotizing enterocolitis (NEC), one of the most common gastrointestinal emergencies and a major cause of morbidity and mortality in preterm neonates. For improved clinical outcomes, early recognition and aggressive management with broad-spectrum or combination antimicrobial agents is most often undertaken to treat NEC [9]. Because of its broad-spectrum activity, meropenem is an agent of great utility [10]. Based on the increasing trends of morbidity and mortality due to multidrug-resistant gram-negative bacterial infections in our neonatal intensive care unit (NICU), and following institutional guidelines, other antibiotics such as vancomycin and colistin are also used [11–13] after infectious disease (ID) consultation. The most common adverse effects of meropenem are constipation or diarrhea, nausea, vomiting, rashes, and diaper-area moniliasis in pediatric patients [14]. Some cases of meropenem-induced neutropenia have been reported [15]. However, no known case of meropenem-induced pancytopenia in neonates has yet been published. Here we report an event of meropenem-induced pancytopenia in a neonate admitted to the NICU of a tertiary-care hospital.
Case presentation
A newborn Pakistani baby was transferred to the intensive care unit due to prematurity, low birth weight, and intrauterine growth retardation. Her birth weight was 0.71 kg and APGAR scores were 3 at 1 minute and 4 at 5 minutes. Delivered by emergency C-section at 29 weeks due to raised blood pressure and fetal distress, she was initially kept on continuous positive airway pressure (CPAP) and given nothing through the mouth, and total parenteral nutrition (TPN) was started. Caffeine was loaded at 20 mg/kg and continued as the standard of care for apnea of prematurity. A prophylactic dose of 1 mg of vitamin K was given. During the first 24 hours, complete blood count (CBC) results were WBC of 18.3 × 103 cells/mm3, ANC of 1244 cells/mm3, platelet count of 166 × 103 cells/mm3, and hemoglobin of 17.8 g/dl. On the second day of life (DOL), ampicillin and gentamicin were started as empirical therapy, and the CBC report showed WBC 4 × 103 cells/mm3, ANC of 760 cells/mm3, platelet count of 152 × 103 cells/mm3, and hemoglobin of 15.9 g/dl. In addition, fluconazole was started as antifungal prophylaxis. The patient was given phototherapy. Chest X-ray and ultrasound of the head were performed, with normal findings. CPAP was tapered to high flow on merit, and blood culture was sent.
On the fourth DOL, the baby developed issues of severe respiratory distress and abdominal distension along with metabolic acidosis. She was intubated and kept on synchronized intermittent mandatory ventilation (SIMV) mode. The CBC results showed ANC of 912 cells/mm3, platelet count of 99 × 103 cells/mm3, and hemoglobin of 12.7 g/dl. Inotropic support was started, and antibiotics were escalated to meropenem 20 mg/kg every 12 hours, vancomycin 10 mg/kg once daily, and colistin at a loading dose of 5 mg/kg with a maintenance dose of 1.5 mg/kg every 12 hours. Blood culture showed no growth. After ID consult, vancomycin was discontinued on the third day and a decision was made to continue meropenem and colistin [11–13] to manage NEC and sepsis.
On the fifth DOL, echocardiogram was performed and showed patent ductus arteriosus (PDA) of 3 mm with severe persistent pulmonary hypertension of the newborn (PPHN). Acetaminophen was started for the next 5 days. On the sixth day of meropenem therapy, the platelet count dropped to 42 × 103 cells/mm3, treated in line with sepsis-associated thrombocytopenia [16], and managed by transfusion of 10 ml/kg platelet units [17]. Meropenem and colistin were discontinued on the eighth day of therapy, and trophic feeding was started. An echocardiogram was repeated on day 11, which showed a closed PDA and moderate PPHN. On the 18th DOL, the child was successfully extubated and kept on high-flow oxygen. There was slow progress in feeding.
On the 22nd DOL, the baby had tachycardia and an episode of 99.7 °F fever. Thus, septic workup was done and showed WBC count of 17.4 × 103 cells/mm3, ANC of 12,632.4 cells/mm3, and platelets of 203 × 103 cells/mm3. C-reactive protein (CRP) was 77 mg/l and renal function was normal (blood urea nitrogen [BUN] of 11 mg/dl and creatinine of 0.2 mg/dl). Meropenem was started in meningitic doses of 40 mg/kg every 8 hours [10] along with vancomycin 15 mg/kg every 12 hours.
In the microbiological investigation, urine and cerebrospinal fluid (CSF) cultures were found to be negative, but the blood culture was positive for Staphylococcus species (not aureus). Blood culture repeated after 48 hours was positive for carbapenem-sensitive Klebsiella pneumoniae. The baby was moved to the isolation room. On the 24th DOL, the baby developed severe thrombocytopenia, with a platelet count of 22 × 103 cells/mm3, managed with the transfusion of 10 ml/kg platelet units [17].
On the 25th DOL, an episode of generalized tonic-clonic fit occurred for which single-dose diazepam and a loading dose of phenobarbitone were given initially and then continued with maintenance doses of phenobarbitone. Due to significant metabolic acidosis and desaturation, the baby was re-intubated. After ID consult, meropenem was continued in meningitic doses and vancomycin was discontinued. SIMV and a central line were placed. TPN was started with nothing per oral status.
Blood gases were monitored, and the baby was extubated after 4 days and switched to CPAP. Phenobarbitone was discontinued after 6 days of therapy, and the baby was seizure-free through the remainder of the hospital stay. All repeat blood cultures were negative for any growth including CSF culture. The ID team was on board and decided to continue meropenem for a total of 14 days post-negative culture in septic doses of 20 mg/kg, and vancomycin was discontinued after 6 days. All repeated blood cultures obtained on the 27th and 30th DOL confirmed no pathogenic growth.
On the 33rd DOL, the CBC report showed WBC of 8.7 × 103 cells/mm3, ANC of 4576 cells/mm3, platelets of 78 × 103 cells/mm3, and hemoglobin of 10.8 g/dl. On the 36th DOL, the CBC report showed WBC of 5.1 × 103 cells/mm3, ANC of 2917 cells/mm3, platelets of 29 × 103 cells/mm3, and hemoglobin of 9.2 g/dl. The baby was managed for thrombocytopenia with platelet transfusion.
On the 37th DOL, hemoglobin dropped to 8.3 g/dl in the evening, and platelet count improved to 63 × 103 cells/mm3, WBC was 4.8 × 103 cells/mm3, and ANC was 1285 cells/mm3. On the 39th DOL, a marked reduction was observed in ANC to 816 cells/mm3, platelets of 38 × 103 cells/mm3, and hemoglobin of 8.3 g/dl, and the baby received blood transfusion to manage it. For constant issues, a hematological consult was taken and a decision was made to manage the baby symptomatically with 10 ml/kg platelet units at a platelet count < 50 [17] and 15 ml/kg packed cell transfusion at hemoglobin < 10 g/dl [18].
On the 40th DOL, meropenem was discontinued 14 days after negative culture (total of 19 days of meropenem therapy). On the same day the platelet count was 34 × 103 cells/mm3, ANC was 818 cells/mm3, and hemoglobin was 10.2 g/dl, and the baby was transfused to manage these issues. After discontinuation of meropenem, the baby was continuously monitored for hematological changes, and low counts persisted for 3 days. Improved ANC of > 1500 cells/mm3 was reported on the fourth day, and platelet count of > 150 × 103 cells/mm3 was reported for the first time on the sixth day of meropenem discontinuation, but hemoglobin was still low (Fig 1). CPAP was tapered gradually to nasal prongs. The peripherally inserted central catheter was removed, and orogastric (OG) tube feeding was commenced. The baby was discharged on the 48th DOL on iron supplements with follow-up monitoring of CBC. Hemoglobin level of 11.2 g/dl was found on the 59th DOL.Fig. 1. Hematological changes and timing of medication during hospitalization
Discussion
Drug-induced pancytopenia is a rare hematological problem in neonatal clinical practices, evaluated based on a complete underlying pathological history, physical examination, and vigilant interpretation of biochemical, radiological, histopathological, and hematological findings [19]. Concerns have been raised about hematological adverse effects of several beta-lactamase inhibitors [8]. This neonatal case documents meropenem-induced pancytopenia and emphasizes cautious laboratory monitoring for patients receiving meropenem therapy.
Sepsis is another known etiology of pancytopenia. Although the neonate in the present case had a blood culture positive for K. pneumoniae, the results of all repeated blood cultures were negative, showing the resolution of sepsis. Van Tuyl et al. [20] also reported a case of a neonate receiving meropenem in meningitic doses of 40 mg/kg/day to treat meropenem-susceptible Enterobacter cloacae in blood culture. The baby developed meropenem-induced neutropenia on the 13th day of therapy, with ANC of 288 cells/mm3. The decision was made to discontinue meropenem on the 19th day of therapy instead of the initially planned 21 days. In the present case, the baby continued to receive meropenem treatment and was managed for hematological problems based on institutional guidelines and culture sensitivity. Initially, hematological changes were not considered as directly meropenem-induced.
Recently published reports also support the notion of carbapenem-induced hematological disorders. A case report by Estella and colleagues [21] described meropenem-induced pancytopenia in a 3-year-old patient at 100 mg/kg given every 8 hours to manage the regrowth of meropenem-sensitive Morganella morganii in CSF cultures. Huang et al. [6] reported a case of meropenem-induced immune thrombocytopenia in a 59-year-old patient, by detecting meropenem-dependent platelet antibodies and platelet count recovery after discontinuation of meropenem. Oka et al. [5] reported the development of severe anemia with clinical signs in a 76-year-old female patient, who received 2 g meropenem per day. On further investigation, they found that a direct antiglobulin test (DAT) was positive for immunoglobulin G (IgG) and C3d, and reported the presence of meropenem-dependent antibodies in the patient’s serum [5].
The absence of drug-dependent antibody testing and bone marrow aspiration prevent us from drawing a firm conclusion regarding the mechanism of meropenem-induced pancytopenia in the present case. However, the hematological findings with the progressive development of thrombocytopenia, anemia, and then neutropenia suggest a possible mechanism of suppression of granulopoiesis or antibody-mediated destruction, as reported in recent studies [5, 6].
During hospitalization, the neonate received other medications, which have been reported to exert hematological effects. The baby initially received ampicillin, gentamicin, and fluconazole, and then received meropenem, colistin, vancomycin, and phenobarbital. However, severe thrombocytopenia developed on the sixth day of the first course of meropenem therapy, when the baby was also on colistin and fluconazole. This issue was resolved when meropenem was discontinued. During the second course of meropenem therapy, the baby again developed severe thrombocytopenia on the third day, while also receiving vancomycin, fluconazole, and phenobarbital. Phenobarbital-induced hematological abnormalities are reported in animal and adult studies [22, 23], and therefore it was discontinued on the sixth day. No seizures were observed but counts did not improve. However, the baby developed severe anemia and neutropenia while receiving fluconazole and meropenem only. After meropenem discontinuation, severe anemia and neutropenia showed a resolving trend for 3 days. Severe neutropenia resolved on the fourth day, and hemoglobin was reported at > 10 g/dl without transfusion on the seventh day of meropenem discontinuation, while fluconazole therapy was continued from the beginning until the 56th DOL, which further confirms the association of meropenem-induced hematological changes in this baby. It was also confirmed that the baby did not experience any additional infection even though she was not discharged on any antibiotic, which correlates with the fast recovery of blood counts after meropenem discontinuation.
Conclusions
In the present neonatal case, the gradual onset of hematological irregularities correlates with the commencement of meropenem therapy, and our observations are also verified by previously published evidence. The follow-up CBC count further established the resolution of pancytopenia after discontinuation of meropenem. Neonatal pancytopenia may lead to serious health complications; therefore, clinicians and pharmacists need to vigilantly monitor CBC counts in this vulnerable population, even when administering meropenem in septic doses for the recommended duration.
Patient perspective
From the perspective of the patient’s father, it was a rare case to have such kind of adverse events in a neonate with the normal treatment regimen. He was shared about all the events and he admired the team for the timely and effectively managing the issues and finally 100% recovery on the follow-ups.
Abbreviations
ANCAbsolute neutrophil count
CBCComplete blood count
DOLDay of life
CPAPContinuous positive airway pressure
TPNTotal parenteral nutrition
SIMVSynchronized intermittent mandatory ventilation
NECNecrotizing enterocolitis
PDAPatent ductus arteriosus
PPHNPersistent pulmonary hypertension of the newborn
CRPC-reactive protein
IDInfectious disease
Publisher's Note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
Acknowledgements
We acknowledge the kind support of Abdul Moiz Hussain for providing technical support in the process of final submission and language review. This study was conducted in the neonatal intensive care unit of Aga Khan University Hospital, Karachi, Pakistan.
Authors’ contributions
GA: Substantial contributions to the conception or design of the work. Performed the study, analysis, or interpretation of patient information. Major contributor in writing the manuscript. KH: Supervised the study and analyzed and interpreted the patient data regarding the hematological changes with therapy. Revised the work critically for important intellectual content. SS: Supervised the study and analyzed and interpreted the patient data regarding the hematological changes with therapy. Final approval of the version published. NM: Wrote the initial draft of the case report. AM: Co-wrote the initial draft. SI: data collection and interpretation. JI: data collection and interpretation. All authors read and approved the final manuscript.
Funding
No source of funding in the research.
Availability of data and materials
All data generated or analyzed during this study are included in the published article. The data sets used and/or analyzed during the current study are available from the corresponding author on reasonable request. Please contact the author for data requests.
Ethics approval and consent to participate
This case report was exempted from formal approval by the Ethical Review Committee, Aga Khan University Karachi, Pakistan.
Consent for publication
Written informed consent was obtained from the patient’s legal guardian(s) for publication of this case report and any accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.
Competing interests
The authors declare that they have no competing interests. | UNK, FROM THE SECOND DAY OF LIFE | DrugDosageText | CC BY | 33509295 | 18,915,789 | 2021-01-29 |
What was the dosage of drug 'CAFFEINE'? | Meropenem-induced pancytopenia in a preterm neonate: a case report.
BACKGROUND
A post-marketing surveillance study has reported an association between meropenem use and the incidence of hematologic abnormalities, including leukopenia, thrombocytopenia, hemolysis, and neutropenia, but the precise incidence in neonates is unknown. Here, we report meropenem-induced pancytopenia in a preterm neonate.
METHODS
A preterm newborn Pakistani received intravenous meropenem 40 mg/kg every 8 hours to treat Klebsiella pneumoniae in blood cultures and suspected meningitis. The baby developed severe thrombocytopenia, with a platelet count of 22 × 103 cells/mm3, low hemoglobin level of 9.7 g/dl, and low absolute neutrophil count (ANC) of 816 cells/mm3 on days 3, 14, and 17 of meropenem therapy, respectively. Based on the blood culture and institutional guidelines, meropenem treatment was continued with monitoring and supportive care for a total of 19 days. After discontinuation of meropenem, the baby was monitored continuously for hematological changes, and low counts persisted for 3 days. ANC improved to > 1500 cells/mm3 on the fourth day, and the platelet count reached > 150 × 103 cells/mm3 for the first time on the seventh day of meropenem discontinuation. All subsequent complete blood count (CBC) reports showed improving trends. The baby was discharged on the 48th day of life (DOL), with follow-up monitoring of CBC. The baby was kept on iron supplements, and hemoglobin level of 11.2 g/dl was observed on the 59th DOL.
CONCLUSIONS
Neonatal pancytopenia may lead to serious health complications; therefore, clinicians and pharmacists need to vigilantly monitor CBC in this vulnerable population, even when administering meropenem in septic doses for the recommended duration.
Background
Pancytopenia is defined as reduced white blood cell (WBC) count, hemoglobin, and platelet count. Pancytopenia occurs when hemoglobin is < 13 g/dl in males and < 12 g/dl in females, absolute neutrophil count (ANC) is < 1500 cells/mm3, and platelet count is < 150 × 103 cells/mm3 [1]. Pancytopenia is considered severe if a patient experiences two or more of the following: hemoglobin < 7 g/dl, ANC < 500 cells/mm3, and platelet count < 50 × 103 cells/mm3. The mechanism underlying pancytopenia mainly involves bone marrow infiltration, bone marrow aplasia, and blood cell destruction that results in peripheral blood leakage [1]. Suppression of bone marrow varies widely in the pediatric population but may occur due to toxins, infection, or malignant cell infiltrates that can lead to hypocellular bone marrow function. Drug-induced pancytopenia is also a rare but secondary cause of bone marrow suppression due to direct bone marrow toxicity, immune-mediated (complement or antibody-mediated) cell destruction, and hapten formation, and directly affects myeloid precursors [2, 3]. An in vitro study of several beta-lactam antibiotics established the presence of well-differentiated myeloid cells and copious granulocyte precursors along with dose-dependent suppression of granulopoiesis [4]. Antibody-mediated hemolytic anemia and thrombocytopenia have also been established in meropenem-treated patients [5, 6]. Several medications can cause pancytopenia including chemotherapeutics, antiepileptics, antidepressants, and antibiotics [3, 5, 7]. A case–control epidemiological surveillance study was conducted over a follow-up period of 78.7 million person-years to assess the incidence of drug-induced agranulocytosis. Around 396 confirmed cases of acute neutropenia were observed, with an overall incidence of 3.5:1 million per year [8]. It was found that agranulocytosis clearly increased the risk of mortality, with a fatality rate of 9.1%. The most common drugs causing agranulocytosis were dipyrone (16%), beta-lactam antibiotics (12.0 %), ticlopidine (11.1%), antithyroid drugs (7.2%), and sulfonamide antibiotics (5.4%) [8].
Meropenem is one of the beta-lactam antibiotics that can cause serious and life-threatening neutropenia. It is a bactericidal broad-spectrum antibiotic with gram-positive, gram-negative, and anaerobic coverage, and is mainly used in the treatment of severe gram-negative infections in neonates including severe sepsis, meningitis, and complicated intra-abdominal infections such as necrotizing enterocolitis (NEC), one of the most common gastrointestinal emergencies and a major cause of morbidity and mortality in preterm neonates. For improved clinical outcomes, early recognition and aggressive management with broad-spectrum or combination antimicrobial agents is most often undertaken to treat NEC [9]. Because of its broad-spectrum activity, meropenem is an agent of great utility [10]. Based on the increasing trends of morbidity and mortality due to multidrug-resistant gram-negative bacterial infections in our neonatal intensive care unit (NICU), and following institutional guidelines, other antibiotics such as vancomycin and colistin are also used [11–13] after infectious disease (ID) consultation. The most common adverse effects of meropenem are constipation or diarrhea, nausea, vomiting, rashes, and diaper-area moniliasis in pediatric patients [14]. Some cases of meropenem-induced neutropenia have been reported [15]. However, no known case of meropenem-induced pancytopenia in neonates has yet been published. Here we report an event of meropenem-induced pancytopenia in a neonate admitted to the NICU of a tertiary-care hospital.
Case presentation
A newborn Pakistani baby was transferred to the intensive care unit due to prematurity, low birth weight, and intrauterine growth retardation. Her birth weight was 0.71 kg and APGAR scores were 3 at 1 minute and 4 at 5 minutes. Delivered by emergency C-section at 29 weeks due to raised blood pressure and fetal distress, she was initially kept on continuous positive airway pressure (CPAP) and given nothing through the mouth, and total parenteral nutrition (TPN) was started. Caffeine was loaded at 20 mg/kg and continued as the standard of care for apnea of prematurity. A prophylactic dose of 1 mg of vitamin K was given. During the first 24 hours, complete blood count (CBC) results were WBC of 18.3 × 103 cells/mm3, ANC of 1244 cells/mm3, platelet count of 166 × 103 cells/mm3, and hemoglobin of 17.8 g/dl. On the second day of life (DOL), ampicillin and gentamicin were started as empirical therapy, and the CBC report showed WBC 4 × 103 cells/mm3, ANC of 760 cells/mm3, platelet count of 152 × 103 cells/mm3, and hemoglobin of 15.9 g/dl. In addition, fluconazole was started as antifungal prophylaxis. The patient was given phototherapy. Chest X-ray and ultrasound of the head were performed, with normal findings. CPAP was tapered to high flow on merit, and blood culture was sent.
On the fourth DOL, the baby developed issues of severe respiratory distress and abdominal distension along with metabolic acidosis. She was intubated and kept on synchronized intermittent mandatory ventilation (SIMV) mode. The CBC results showed ANC of 912 cells/mm3, platelet count of 99 × 103 cells/mm3, and hemoglobin of 12.7 g/dl. Inotropic support was started, and antibiotics were escalated to meropenem 20 mg/kg every 12 hours, vancomycin 10 mg/kg once daily, and colistin at a loading dose of 5 mg/kg with a maintenance dose of 1.5 mg/kg every 12 hours. Blood culture showed no growth. After ID consult, vancomycin was discontinued on the third day and a decision was made to continue meropenem and colistin [11–13] to manage NEC and sepsis.
On the fifth DOL, echocardiogram was performed and showed patent ductus arteriosus (PDA) of 3 mm with severe persistent pulmonary hypertension of the newborn (PPHN). Acetaminophen was started for the next 5 days. On the sixth day of meropenem therapy, the platelet count dropped to 42 × 103 cells/mm3, treated in line with sepsis-associated thrombocytopenia [16], and managed by transfusion of 10 ml/kg platelet units [17]. Meropenem and colistin were discontinued on the eighth day of therapy, and trophic feeding was started. An echocardiogram was repeated on day 11, which showed a closed PDA and moderate PPHN. On the 18th DOL, the child was successfully extubated and kept on high-flow oxygen. There was slow progress in feeding.
On the 22nd DOL, the baby had tachycardia and an episode of 99.7 °F fever. Thus, septic workup was done and showed WBC count of 17.4 × 103 cells/mm3, ANC of 12,632.4 cells/mm3, and platelets of 203 × 103 cells/mm3. C-reactive protein (CRP) was 77 mg/l and renal function was normal (blood urea nitrogen [BUN] of 11 mg/dl and creatinine of 0.2 mg/dl). Meropenem was started in meningitic doses of 40 mg/kg every 8 hours [10] along with vancomycin 15 mg/kg every 12 hours.
In the microbiological investigation, urine and cerebrospinal fluid (CSF) cultures were found to be negative, but the blood culture was positive for Staphylococcus species (not aureus). Blood culture repeated after 48 hours was positive for carbapenem-sensitive Klebsiella pneumoniae. The baby was moved to the isolation room. On the 24th DOL, the baby developed severe thrombocytopenia, with a platelet count of 22 × 103 cells/mm3, managed with the transfusion of 10 ml/kg platelet units [17].
On the 25th DOL, an episode of generalized tonic-clonic fit occurred for which single-dose diazepam and a loading dose of phenobarbitone were given initially and then continued with maintenance doses of phenobarbitone. Due to significant metabolic acidosis and desaturation, the baby was re-intubated. After ID consult, meropenem was continued in meningitic doses and vancomycin was discontinued. SIMV and a central line were placed. TPN was started with nothing per oral status.
Blood gases were monitored, and the baby was extubated after 4 days and switched to CPAP. Phenobarbitone was discontinued after 6 days of therapy, and the baby was seizure-free through the remainder of the hospital stay. All repeat blood cultures were negative for any growth including CSF culture. The ID team was on board and decided to continue meropenem for a total of 14 days post-negative culture in septic doses of 20 mg/kg, and vancomycin was discontinued after 6 days. All repeated blood cultures obtained on the 27th and 30th DOL confirmed no pathogenic growth.
On the 33rd DOL, the CBC report showed WBC of 8.7 × 103 cells/mm3, ANC of 4576 cells/mm3, platelets of 78 × 103 cells/mm3, and hemoglobin of 10.8 g/dl. On the 36th DOL, the CBC report showed WBC of 5.1 × 103 cells/mm3, ANC of 2917 cells/mm3, platelets of 29 × 103 cells/mm3, and hemoglobin of 9.2 g/dl. The baby was managed for thrombocytopenia with platelet transfusion.
On the 37th DOL, hemoglobin dropped to 8.3 g/dl in the evening, and platelet count improved to 63 × 103 cells/mm3, WBC was 4.8 × 103 cells/mm3, and ANC was 1285 cells/mm3. On the 39th DOL, a marked reduction was observed in ANC to 816 cells/mm3, platelets of 38 × 103 cells/mm3, and hemoglobin of 8.3 g/dl, and the baby received blood transfusion to manage it. For constant issues, a hematological consult was taken and a decision was made to manage the baby symptomatically with 10 ml/kg platelet units at a platelet count < 50 [17] and 15 ml/kg packed cell transfusion at hemoglobin < 10 g/dl [18].
On the 40th DOL, meropenem was discontinued 14 days after negative culture (total of 19 days of meropenem therapy). On the same day the platelet count was 34 × 103 cells/mm3, ANC was 818 cells/mm3, and hemoglobin was 10.2 g/dl, and the baby was transfused to manage these issues. After discontinuation of meropenem, the baby was continuously monitored for hematological changes, and low counts persisted for 3 days. Improved ANC of > 1500 cells/mm3 was reported on the fourth day, and platelet count of > 150 × 103 cells/mm3 was reported for the first time on the sixth day of meropenem discontinuation, but hemoglobin was still low (Fig 1). CPAP was tapered gradually to nasal prongs. The peripherally inserted central catheter was removed, and orogastric (OG) tube feeding was commenced. The baby was discharged on the 48th DOL on iron supplements with follow-up monitoring of CBC. Hemoglobin level of 11.2 g/dl was found on the 59th DOL.Fig. 1. Hematological changes and timing of medication during hospitalization
Discussion
Drug-induced pancytopenia is a rare hematological problem in neonatal clinical practices, evaluated based on a complete underlying pathological history, physical examination, and vigilant interpretation of biochemical, radiological, histopathological, and hematological findings [19]. Concerns have been raised about hematological adverse effects of several beta-lactamase inhibitors [8]. This neonatal case documents meropenem-induced pancytopenia and emphasizes cautious laboratory monitoring for patients receiving meropenem therapy.
Sepsis is another known etiology of pancytopenia. Although the neonate in the present case had a blood culture positive for K. pneumoniae, the results of all repeated blood cultures were negative, showing the resolution of sepsis. Van Tuyl et al. [20] also reported a case of a neonate receiving meropenem in meningitic doses of 40 mg/kg/day to treat meropenem-susceptible Enterobacter cloacae in blood culture. The baby developed meropenem-induced neutropenia on the 13th day of therapy, with ANC of 288 cells/mm3. The decision was made to discontinue meropenem on the 19th day of therapy instead of the initially planned 21 days. In the present case, the baby continued to receive meropenem treatment and was managed for hematological problems based on institutional guidelines and culture sensitivity. Initially, hematological changes were not considered as directly meropenem-induced.
Recently published reports also support the notion of carbapenem-induced hematological disorders. A case report by Estella and colleagues [21] described meropenem-induced pancytopenia in a 3-year-old patient at 100 mg/kg given every 8 hours to manage the regrowth of meropenem-sensitive Morganella morganii in CSF cultures. Huang et al. [6] reported a case of meropenem-induced immune thrombocytopenia in a 59-year-old patient, by detecting meropenem-dependent platelet antibodies and platelet count recovery after discontinuation of meropenem. Oka et al. [5] reported the development of severe anemia with clinical signs in a 76-year-old female patient, who received 2 g meropenem per day. On further investigation, they found that a direct antiglobulin test (DAT) was positive for immunoglobulin G (IgG) and C3d, and reported the presence of meropenem-dependent antibodies in the patient’s serum [5].
The absence of drug-dependent antibody testing and bone marrow aspiration prevent us from drawing a firm conclusion regarding the mechanism of meropenem-induced pancytopenia in the present case. However, the hematological findings with the progressive development of thrombocytopenia, anemia, and then neutropenia suggest a possible mechanism of suppression of granulopoiesis or antibody-mediated destruction, as reported in recent studies [5, 6].
During hospitalization, the neonate received other medications, which have been reported to exert hematological effects. The baby initially received ampicillin, gentamicin, and fluconazole, and then received meropenem, colistin, vancomycin, and phenobarbital. However, severe thrombocytopenia developed on the sixth day of the first course of meropenem therapy, when the baby was also on colistin and fluconazole. This issue was resolved when meropenem was discontinued. During the second course of meropenem therapy, the baby again developed severe thrombocytopenia on the third day, while also receiving vancomycin, fluconazole, and phenobarbital. Phenobarbital-induced hematological abnormalities are reported in animal and adult studies [22, 23], and therefore it was discontinued on the sixth day. No seizures were observed but counts did not improve. However, the baby developed severe anemia and neutropenia while receiving fluconazole and meropenem only. After meropenem discontinuation, severe anemia and neutropenia showed a resolving trend for 3 days. Severe neutropenia resolved on the fourth day, and hemoglobin was reported at > 10 g/dl without transfusion on the seventh day of meropenem discontinuation, while fluconazole therapy was continued from the beginning until the 56th DOL, which further confirms the association of meropenem-induced hematological changes in this baby. It was also confirmed that the baby did not experience any additional infection even though she was not discharged on any antibiotic, which correlates with the fast recovery of blood counts after meropenem discontinuation.
Conclusions
In the present neonatal case, the gradual onset of hematological irregularities correlates with the commencement of meropenem therapy, and our observations are also verified by previously published evidence. The follow-up CBC count further established the resolution of pancytopenia after discontinuation of meropenem. Neonatal pancytopenia may lead to serious health complications; therefore, clinicians and pharmacists need to vigilantly monitor CBC counts in this vulnerable population, even when administering meropenem in septic doses for the recommended duration.
Patient perspective
From the perspective of the patient’s father, it was a rare case to have such kind of adverse events in a neonate with the normal treatment regimen. He was shared about all the events and he admired the team for the timely and effectively managing the issues and finally 100% recovery on the follow-ups.
Abbreviations
ANCAbsolute neutrophil count
CBCComplete blood count
DOLDay of life
CPAPContinuous positive airway pressure
TPNTotal parenteral nutrition
SIMVSynchronized intermittent mandatory ventilation
NECNecrotizing enterocolitis
PDAPatent ductus arteriosus
PPHNPersistent pulmonary hypertension of the newborn
CRPC-reactive protein
IDInfectious disease
Publisher's Note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
Acknowledgements
We acknowledge the kind support of Abdul Moiz Hussain for providing technical support in the process of final submission and language review. This study was conducted in the neonatal intensive care unit of Aga Khan University Hospital, Karachi, Pakistan.
Authors’ contributions
GA: Substantial contributions to the conception or design of the work. Performed the study, analysis, or interpretation of patient information. Major contributor in writing the manuscript. KH: Supervised the study and analyzed and interpreted the patient data regarding the hematological changes with therapy. Revised the work critically for important intellectual content. SS: Supervised the study and analyzed and interpreted the patient data regarding the hematological changes with therapy. Final approval of the version published. NM: Wrote the initial draft of the case report. AM: Co-wrote the initial draft. SI: data collection and interpretation. JI: data collection and interpretation. All authors read and approved the final manuscript.
Funding
No source of funding in the research.
Availability of data and materials
All data generated or analyzed during this study are included in the published article. The data sets used and/or analyzed during the current study are available from the corresponding author on reasonable request. Please contact the author for data requests.
Ethics approval and consent to participate
This case report was exempted from formal approval by the Ethical Review Committee, Aga Khan University Karachi, Pakistan.
Consent for publication
Written informed consent was obtained from the patient’s legal guardian(s) for publication of this case report and any accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.
Competing interests
The authors declare that they have no competing interests. | 20 MG/KG, FROM THE FIRST DAY OF LIFE | DrugDosageText | CC BY | 33509295 | 18,915,789 | 2021-01-29 |
What was the dosage of drug 'DIAZEPAM'? | Meropenem-induced pancytopenia in a preterm neonate: a case report.
BACKGROUND
A post-marketing surveillance study has reported an association between meropenem use and the incidence of hematologic abnormalities, including leukopenia, thrombocytopenia, hemolysis, and neutropenia, but the precise incidence in neonates is unknown. Here, we report meropenem-induced pancytopenia in a preterm neonate.
METHODS
A preterm newborn Pakistani received intravenous meropenem 40 mg/kg every 8 hours to treat Klebsiella pneumoniae in blood cultures and suspected meningitis. The baby developed severe thrombocytopenia, with a platelet count of 22 × 103 cells/mm3, low hemoglobin level of 9.7 g/dl, and low absolute neutrophil count (ANC) of 816 cells/mm3 on days 3, 14, and 17 of meropenem therapy, respectively. Based on the blood culture and institutional guidelines, meropenem treatment was continued with monitoring and supportive care for a total of 19 days. After discontinuation of meropenem, the baby was monitored continuously for hematological changes, and low counts persisted for 3 days. ANC improved to > 1500 cells/mm3 on the fourth day, and the platelet count reached > 150 × 103 cells/mm3 for the first time on the seventh day of meropenem discontinuation. All subsequent complete blood count (CBC) reports showed improving trends. The baby was discharged on the 48th day of life (DOL), with follow-up monitoring of CBC. The baby was kept on iron supplements, and hemoglobin level of 11.2 g/dl was observed on the 59th DOL.
CONCLUSIONS
Neonatal pancytopenia may lead to serious health complications; therefore, clinicians and pharmacists need to vigilantly monitor CBC in this vulnerable population, even when administering meropenem in septic doses for the recommended duration.
Background
Pancytopenia is defined as reduced white blood cell (WBC) count, hemoglobin, and platelet count. Pancytopenia occurs when hemoglobin is < 13 g/dl in males and < 12 g/dl in females, absolute neutrophil count (ANC) is < 1500 cells/mm3, and platelet count is < 150 × 103 cells/mm3 [1]. Pancytopenia is considered severe if a patient experiences two or more of the following: hemoglobin < 7 g/dl, ANC < 500 cells/mm3, and platelet count < 50 × 103 cells/mm3. The mechanism underlying pancytopenia mainly involves bone marrow infiltration, bone marrow aplasia, and blood cell destruction that results in peripheral blood leakage [1]. Suppression of bone marrow varies widely in the pediatric population but may occur due to toxins, infection, or malignant cell infiltrates that can lead to hypocellular bone marrow function. Drug-induced pancytopenia is also a rare but secondary cause of bone marrow suppression due to direct bone marrow toxicity, immune-mediated (complement or antibody-mediated) cell destruction, and hapten formation, and directly affects myeloid precursors [2, 3]. An in vitro study of several beta-lactam antibiotics established the presence of well-differentiated myeloid cells and copious granulocyte precursors along with dose-dependent suppression of granulopoiesis [4]. Antibody-mediated hemolytic anemia and thrombocytopenia have also been established in meropenem-treated patients [5, 6]. Several medications can cause pancytopenia including chemotherapeutics, antiepileptics, antidepressants, and antibiotics [3, 5, 7]. A case–control epidemiological surveillance study was conducted over a follow-up period of 78.7 million person-years to assess the incidence of drug-induced agranulocytosis. Around 396 confirmed cases of acute neutropenia were observed, with an overall incidence of 3.5:1 million per year [8]. It was found that agranulocytosis clearly increased the risk of mortality, with a fatality rate of 9.1%. The most common drugs causing agranulocytosis were dipyrone (16%), beta-lactam antibiotics (12.0 %), ticlopidine (11.1%), antithyroid drugs (7.2%), and sulfonamide antibiotics (5.4%) [8].
Meropenem is one of the beta-lactam antibiotics that can cause serious and life-threatening neutropenia. It is a bactericidal broad-spectrum antibiotic with gram-positive, gram-negative, and anaerobic coverage, and is mainly used in the treatment of severe gram-negative infections in neonates including severe sepsis, meningitis, and complicated intra-abdominal infections such as necrotizing enterocolitis (NEC), one of the most common gastrointestinal emergencies and a major cause of morbidity and mortality in preterm neonates. For improved clinical outcomes, early recognition and aggressive management with broad-spectrum or combination antimicrobial agents is most often undertaken to treat NEC [9]. Because of its broad-spectrum activity, meropenem is an agent of great utility [10]. Based on the increasing trends of morbidity and mortality due to multidrug-resistant gram-negative bacterial infections in our neonatal intensive care unit (NICU), and following institutional guidelines, other antibiotics such as vancomycin and colistin are also used [11–13] after infectious disease (ID) consultation. The most common adverse effects of meropenem are constipation or diarrhea, nausea, vomiting, rashes, and diaper-area moniliasis in pediatric patients [14]. Some cases of meropenem-induced neutropenia have been reported [15]. However, no known case of meropenem-induced pancytopenia in neonates has yet been published. Here we report an event of meropenem-induced pancytopenia in a neonate admitted to the NICU of a tertiary-care hospital.
Case presentation
A newborn Pakistani baby was transferred to the intensive care unit due to prematurity, low birth weight, and intrauterine growth retardation. Her birth weight was 0.71 kg and APGAR scores were 3 at 1 minute and 4 at 5 minutes. Delivered by emergency C-section at 29 weeks due to raised blood pressure and fetal distress, she was initially kept on continuous positive airway pressure (CPAP) and given nothing through the mouth, and total parenteral nutrition (TPN) was started. Caffeine was loaded at 20 mg/kg and continued as the standard of care for apnea of prematurity. A prophylactic dose of 1 mg of vitamin K was given. During the first 24 hours, complete blood count (CBC) results were WBC of 18.3 × 103 cells/mm3, ANC of 1244 cells/mm3, platelet count of 166 × 103 cells/mm3, and hemoglobin of 17.8 g/dl. On the second day of life (DOL), ampicillin and gentamicin were started as empirical therapy, and the CBC report showed WBC 4 × 103 cells/mm3, ANC of 760 cells/mm3, platelet count of 152 × 103 cells/mm3, and hemoglobin of 15.9 g/dl. In addition, fluconazole was started as antifungal prophylaxis. The patient was given phototherapy. Chest X-ray and ultrasound of the head were performed, with normal findings. CPAP was tapered to high flow on merit, and blood culture was sent.
On the fourth DOL, the baby developed issues of severe respiratory distress and abdominal distension along with metabolic acidosis. She was intubated and kept on synchronized intermittent mandatory ventilation (SIMV) mode. The CBC results showed ANC of 912 cells/mm3, platelet count of 99 × 103 cells/mm3, and hemoglobin of 12.7 g/dl. Inotropic support was started, and antibiotics were escalated to meropenem 20 mg/kg every 12 hours, vancomycin 10 mg/kg once daily, and colistin at a loading dose of 5 mg/kg with a maintenance dose of 1.5 mg/kg every 12 hours. Blood culture showed no growth. After ID consult, vancomycin was discontinued on the third day and a decision was made to continue meropenem and colistin [11–13] to manage NEC and sepsis.
On the fifth DOL, echocardiogram was performed and showed patent ductus arteriosus (PDA) of 3 mm with severe persistent pulmonary hypertension of the newborn (PPHN). Acetaminophen was started for the next 5 days. On the sixth day of meropenem therapy, the platelet count dropped to 42 × 103 cells/mm3, treated in line with sepsis-associated thrombocytopenia [16], and managed by transfusion of 10 ml/kg platelet units [17]. Meropenem and colistin were discontinued on the eighth day of therapy, and trophic feeding was started. An echocardiogram was repeated on day 11, which showed a closed PDA and moderate PPHN. On the 18th DOL, the child was successfully extubated and kept on high-flow oxygen. There was slow progress in feeding.
On the 22nd DOL, the baby had tachycardia and an episode of 99.7 °F fever. Thus, septic workup was done and showed WBC count of 17.4 × 103 cells/mm3, ANC of 12,632.4 cells/mm3, and platelets of 203 × 103 cells/mm3. C-reactive protein (CRP) was 77 mg/l and renal function was normal (blood urea nitrogen [BUN] of 11 mg/dl and creatinine of 0.2 mg/dl). Meropenem was started in meningitic doses of 40 mg/kg every 8 hours [10] along with vancomycin 15 mg/kg every 12 hours.
In the microbiological investigation, urine and cerebrospinal fluid (CSF) cultures were found to be negative, but the blood culture was positive for Staphylococcus species (not aureus). Blood culture repeated after 48 hours was positive for carbapenem-sensitive Klebsiella pneumoniae. The baby was moved to the isolation room. On the 24th DOL, the baby developed severe thrombocytopenia, with a platelet count of 22 × 103 cells/mm3, managed with the transfusion of 10 ml/kg platelet units [17].
On the 25th DOL, an episode of generalized tonic-clonic fit occurred for which single-dose diazepam and a loading dose of phenobarbitone were given initially and then continued with maintenance doses of phenobarbitone. Due to significant metabolic acidosis and desaturation, the baby was re-intubated. After ID consult, meropenem was continued in meningitic doses and vancomycin was discontinued. SIMV and a central line were placed. TPN was started with nothing per oral status.
Blood gases were monitored, and the baby was extubated after 4 days and switched to CPAP. Phenobarbitone was discontinued after 6 days of therapy, and the baby was seizure-free through the remainder of the hospital stay. All repeat blood cultures were negative for any growth including CSF culture. The ID team was on board and decided to continue meropenem for a total of 14 days post-negative culture in septic doses of 20 mg/kg, and vancomycin was discontinued after 6 days. All repeated blood cultures obtained on the 27th and 30th DOL confirmed no pathogenic growth.
On the 33rd DOL, the CBC report showed WBC of 8.7 × 103 cells/mm3, ANC of 4576 cells/mm3, platelets of 78 × 103 cells/mm3, and hemoglobin of 10.8 g/dl. On the 36th DOL, the CBC report showed WBC of 5.1 × 103 cells/mm3, ANC of 2917 cells/mm3, platelets of 29 × 103 cells/mm3, and hemoglobin of 9.2 g/dl. The baby was managed for thrombocytopenia with platelet transfusion.
On the 37th DOL, hemoglobin dropped to 8.3 g/dl in the evening, and platelet count improved to 63 × 103 cells/mm3, WBC was 4.8 × 103 cells/mm3, and ANC was 1285 cells/mm3. On the 39th DOL, a marked reduction was observed in ANC to 816 cells/mm3, platelets of 38 × 103 cells/mm3, and hemoglobin of 8.3 g/dl, and the baby received blood transfusion to manage it. For constant issues, a hematological consult was taken and a decision was made to manage the baby symptomatically with 10 ml/kg platelet units at a platelet count < 50 [17] and 15 ml/kg packed cell transfusion at hemoglobin < 10 g/dl [18].
On the 40th DOL, meropenem was discontinued 14 days after negative culture (total of 19 days of meropenem therapy). On the same day the platelet count was 34 × 103 cells/mm3, ANC was 818 cells/mm3, and hemoglobin was 10.2 g/dl, and the baby was transfused to manage these issues. After discontinuation of meropenem, the baby was continuously monitored for hematological changes, and low counts persisted for 3 days. Improved ANC of > 1500 cells/mm3 was reported on the fourth day, and platelet count of > 150 × 103 cells/mm3 was reported for the first time on the sixth day of meropenem discontinuation, but hemoglobin was still low (Fig 1). CPAP was tapered gradually to nasal prongs. The peripherally inserted central catheter was removed, and orogastric (OG) tube feeding was commenced. The baby was discharged on the 48th DOL on iron supplements with follow-up monitoring of CBC. Hemoglobin level of 11.2 g/dl was found on the 59th DOL.Fig. 1. Hematological changes and timing of medication during hospitalization
Discussion
Drug-induced pancytopenia is a rare hematological problem in neonatal clinical practices, evaluated based on a complete underlying pathological history, physical examination, and vigilant interpretation of biochemical, radiological, histopathological, and hematological findings [19]. Concerns have been raised about hematological adverse effects of several beta-lactamase inhibitors [8]. This neonatal case documents meropenem-induced pancytopenia and emphasizes cautious laboratory monitoring for patients receiving meropenem therapy.
Sepsis is another known etiology of pancytopenia. Although the neonate in the present case had a blood culture positive for K. pneumoniae, the results of all repeated blood cultures were negative, showing the resolution of sepsis. Van Tuyl et al. [20] also reported a case of a neonate receiving meropenem in meningitic doses of 40 mg/kg/day to treat meropenem-susceptible Enterobacter cloacae in blood culture. The baby developed meropenem-induced neutropenia on the 13th day of therapy, with ANC of 288 cells/mm3. The decision was made to discontinue meropenem on the 19th day of therapy instead of the initially planned 21 days. In the present case, the baby continued to receive meropenem treatment and was managed for hematological problems based on institutional guidelines and culture sensitivity. Initially, hematological changes were not considered as directly meropenem-induced.
Recently published reports also support the notion of carbapenem-induced hematological disorders. A case report by Estella and colleagues [21] described meropenem-induced pancytopenia in a 3-year-old patient at 100 mg/kg given every 8 hours to manage the regrowth of meropenem-sensitive Morganella morganii in CSF cultures. Huang et al. [6] reported a case of meropenem-induced immune thrombocytopenia in a 59-year-old patient, by detecting meropenem-dependent platelet antibodies and platelet count recovery after discontinuation of meropenem. Oka et al. [5] reported the development of severe anemia with clinical signs in a 76-year-old female patient, who received 2 g meropenem per day. On further investigation, they found that a direct antiglobulin test (DAT) was positive for immunoglobulin G (IgG) and C3d, and reported the presence of meropenem-dependent antibodies in the patient’s serum [5].
The absence of drug-dependent antibody testing and bone marrow aspiration prevent us from drawing a firm conclusion regarding the mechanism of meropenem-induced pancytopenia in the present case. However, the hematological findings with the progressive development of thrombocytopenia, anemia, and then neutropenia suggest a possible mechanism of suppression of granulopoiesis or antibody-mediated destruction, as reported in recent studies [5, 6].
During hospitalization, the neonate received other medications, which have been reported to exert hematological effects. The baby initially received ampicillin, gentamicin, and fluconazole, and then received meropenem, colistin, vancomycin, and phenobarbital. However, severe thrombocytopenia developed on the sixth day of the first course of meropenem therapy, when the baby was also on colistin and fluconazole. This issue was resolved when meropenem was discontinued. During the second course of meropenem therapy, the baby again developed severe thrombocytopenia on the third day, while also receiving vancomycin, fluconazole, and phenobarbital. Phenobarbital-induced hematological abnormalities are reported in animal and adult studies [22, 23], and therefore it was discontinued on the sixth day. No seizures were observed but counts did not improve. However, the baby developed severe anemia and neutropenia while receiving fluconazole and meropenem only. After meropenem discontinuation, severe anemia and neutropenia showed a resolving trend for 3 days. Severe neutropenia resolved on the fourth day, and hemoglobin was reported at > 10 g/dl without transfusion on the seventh day of meropenem discontinuation, while fluconazole therapy was continued from the beginning until the 56th DOL, which further confirms the association of meropenem-induced hematological changes in this baby. It was also confirmed that the baby did not experience any additional infection even though she was not discharged on any antibiotic, which correlates with the fast recovery of blood counts after meropenem discontinuation.
Conclusions
In the present neonatal case, the gradual onset of hematological irregularities correlates with the commencement of meropenem therapy, and our observations are also verified by previously published evidence. The follow-up CBC count further established the resolution of pancytopenia after discontinuation of meropenem. Neonatal pancytopenia may lead to serious health complications; therefore, clinicians and pharmacists need to vigilantly monitor CBC counts in this vulnerable population, even when administering meropenem in septic doses for the recommended duration.
Patient perspective
From the perspective of the patient’s father, it was a rare case to have such kind of adverse events in a neonate with the normal treatment regimen. He was shared about all the events and he admired the team for the timely and effectively managing the issues and finally 100% recovery on the follow-ups.
Abbreviations
ANCAbsolute neutrophil count
CBCComplete blood count
DOLDay of life
CPAPContinuous positive airway pressure
TPNTotal parenteral nutrition
SIMVSynchronized intermittent mandatory ventilation
NECNecrotizing enterocolitis
PDAPatent ductus arteriosus
PPHNPersistent pulmonary hypertension of the newborn
CRPC-reactive protein
IDInfectious disease
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Acknowledgements
We acknowledge the kind support of Abdul Moiz Hussain for providing technical support in the process of final submission and language review. This study was conducted in the neonatal intensive care unit of Aga Khan University Hospital, Karachi, Pakistan.
Authors’ contributions
GA: Substantial contributions to the conception or design of the work. Performed the study, analysis, or interpretation of patient information. Major contributor in writing the manuscript. KH: Supervised the study and analyzed and interpreted the patient data regarding the hematological changes with therapy. Revised the work critically for important intellectual content. SS: Supervised the study and analyzed and interpreted the patient data regarding the hematological changes with therapy. Final approval of the version published. NM: Wrote the initial draft of the case report. AM: Co-wrote the initial draft. SI: data collection and interpretation. JI: data collection and interpretation. All authors read and approved the final manuscript.
Funding
No source of funding in the research.
Availability of data and materials
All data generated or analyzed during this study are included in the published article. The data sets used and/or analyzed during the current study are available from the corresponding author on reasonable request. Please contact the author for data requests.
Ethics approval and consent to participate
This case report was exempted from formal approval by the Ethical Review Committee, Aga Khan University Karachi, Pakistan.
Consent for publication
Written informed consent was obtained from the patient’s legal guardian(s) for publication of this case report and any accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.
Competing interests
The authors declare that they have no competing interests. | SINGLE?DOSE, ON THE 25TH DOL | DrugDosageText | CC BY | 33509295 | 18,915,789 | 2021-01-29 |
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